Nokea
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?
- B. After this procedure
- C. you will feel much better.
- D. Tell me why you are scared to have this procedure.
Correct Answer: D
Rationale: Rationale: The correct response is D because it demonstrates active listening and empathy by encouraging the client to express their fears. By asking the client to elaborate on their fears, the nurse can address specific concerns and provide appropriate support. This promotes trust and open communication between the nurse and client, leading to better outcomes.
Incorrect Responses:
A: This response assumes the fear is related to needles and does not address the client's specific concerns about the procedure.
B: This response is incomplete and does not acknowledge the client's fear.
C: This response minimizes the client's feelings and does not address the underlying fear.
Overall, these responses fail to address the client's emotional needs and may not effectively alleviate their fear or anxiety.
You may also like to solve these questions
A nurse is providing discharge teaching to a client who had a bilateral architectomy. The nurse should instruct the client to expect which of the following symptoms?
- A. Hypoglycemia
- B. Increased libido
- C. Hot flashes
- D. Increased muscle mass
Correct Answer: A
Rationale: The correct answer is A: Hypoglycemia. After a bilateral adrenalectomy, the client will have decreased cortisol production, leading to adrenal insufficiency. This can result in hypoglycemia due to decreased glucose regulation. Increased libido (B) and increased muscle mass (D) are not typical symptoms following this procedure. Hot flashes (C) are more commonly associated with menopause.
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
- A. Loss of peripheral vision
- B. Inability to smell
- C. Deviation of the tongue from midline
- D. Disequilibrium with movement
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve. Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve. Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
- A. Increase phosphorus intake
- B. Decrease carbohydrate intake
- C. Decrease protein intake
- D. Increase potassium intake
Correct Answer: C
Rationale: The correct answer is C: Decrease protein intake. Nephrotic syndrome causes protein loss through urine, leading to hypoalbuminemia and edema. Decreasing protein intake can help reduce proteinuria and decrease the workload on the kidneys. Increasing phosphorus intake (A) can worsen kidney function. Decreasing carbohydrate intake (B) is not directly related to managing nephrotic syndrome. Increasing potassium intake (D) is not recommended as it can lead to hyperkalemia in individuals with kidney issues.
A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I plan to take this medication for 1 week.
- B. I should take an antacid with each dose of this medication.
- C. This medication may cause my blood pressure to increase.
- D. I will have my liver function tested while I am taking this medication.
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This is the correct answer because isoniazid (INH) is known to potentially cause liver toxicity. Monitoring liver function tests is crucial to detect any signs of liver damage early. Choice A is incorrect as INH treatment for tuberculosis typically lasts 6-9 months, not just 1 week. Choice B is incorrect because antacids can decrease the absorption of INH. Choice C is incorrect as INH does not typically cause an increase in blood pressure.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample
- B. Check the clients' vital signs
- C. Stop the infusion
- D. Administer oxygen to the client
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client is showing signs of a transfusion reaction, which can be serious. Stopping the infusion is the first priority to prevent further complications. Vital signs should be checked next to assess the client's condition. Collecting a urine sample is not a priority in this situation. Administering oxygen may be necessary depending on the client's condition, but stopping the infusion takes precedence.