Nokea
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. This is the correct action as it validates the client's feelings and provides reassurance that anger is a common emotion when dealing with a cancer diagnosis. By acknowledging the client's emotions, the nurse can build trust and support the client through the grieving process.
A: Discussing risk factors is not the priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage.
C: Providing written information about loss and grief phases may not address the client's current emotional state.
In summary, option D is the best choice as it acknowledges the client's feelings and offers support during a difficult time.
You may also like to solve these questions
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is to check the client for injuries first because ensuring the client's immediate safety and well-being is the top priority. By assessing for injuries, the nurse can determine the severity of the situation and provide necessary interventions promptly. Moving hazardous objects (B) can wait until after ensuring the client's safety. Notifying the provider (C) can also be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important for gathering information but is not as urgent as checking for injuries.
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
- A. Wear loose-fitting underwear.
- B. Take a bubble bath after intercourse.
- C. Drink four 240 mL (8 oz) glasses of water each day.
- D. Void every 5 to 6 hr during the day.
Correct Answer: A
Rationale: Correct Answer: A: Wear loose-fitting underwear.
Rationale:
1. Loose-fitting underwear allows for better air circulation, reducing moisture and bacterial growth.
2. Tight clothing can create a warm, moist environment ideal for bacterial growth.
3. Preventing moisture buildup can help reduce the risk of urinary tract infections.
Summary of other choices:
B: Taking a bubble bath after intercourse can introduce bacteria into the urinary tract, increasing the risk of infection.
C: Drinking water is important for overall health but does not directly prevent urinary tract infections.
D: Voiding every 5 to 6 hours is a good practice, but it does not directly address the prevention of urinary tract infections.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities.
- B. A client who has a hip fracture and a new onset of tachypnea.
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- D. A client who has diabetes mellitus and an HbA1C of 6.8%.
Correct Answer: B
Rationale: The correct answer is B because a client with a hip fracture and new onset of tachypnea may have a pulmonary embolism, a life-threatening complication that requires immediate assessment and intervention. Tachypnea can indicate hypoxia, which can be fatal if not addressed promptly. The nurse should prioritize assessing this client to ensure timely management and prevent further deterioration.
Clients A, C, and D do not present with immediate life-threatening conditions that require urgent assessment compared to client B. Client A's weakness in the lower extremities, client C's sinus arrhythmia, and client D's HbA1C level do not pose immediate risks to their health. Therefore, the nurse should assess client B first to address the potential pulmonary embolism.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The nurse should observe the palms of the hands to assess for cyanosis in a client with dark skin because this area is less pigmented and cyanosis is easier to detect. Palms have thinner skin and blood vessels are closer to the surface, making it more likely to show changes in color due to decreased oxygen levels. The sacrum, shoulders, and areas of trauma may not accurately reflect cyanosis in dark-skinned individuals due to the differences in skin pigmentation and thickness. By focusing on the palms, the nurse can accurately assess for cyanosis and provide appropriate care.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences.
- C. Speak directly to the client.
- D. Use gestures to convey meaning.
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is crucial as it maintains a connection with the client, shows respect, and ensures understanding. Speaking to the interpreter directly can lead to misinterpretation. Speaking slowly (A) may come across as patronizing. Pausing in the middle of sentences (B) can disrupt communication flow. Using gestures (D) may help but should not replace direct verbal communication. The other choices are not as effective in ensuring clear communication and building trust with the client.