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: C
Rationale: The correct answer is C: Provide the client with written information about the phases of loss and grief. This is the most appropriate action as the client is expressing anger, which is a normal part of the grieving process. By providing information about the phases of loss and grief, the nurse can help the client understand his emotions and cope with them effectively.
A: Discussing risk factors for colon cancer is not the immediate priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage when he is dealing with emotional distress.
D: Reassuring the client that his response is expected is helpful, but providing information on coping mechanisms is more beneficial in this situation.
You may also like to solve these questions
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
- A. A lesion with uniform pigmentation
- B. New appearance of petechiae
- C. A mole with an asymmetrical appearance
- D. The presence of a papule
Correct Answer: C
Rationale: The correct answer is C: A mole with an asymmetrical appearance. This is indicative of a potential skin malignancy such as melanoma. The asymmetry suggests irregular growth patterns, which can be a sign of cancerous cells. Other choices, such as A (lesion with uniform pigmentation), B (petechiae), and D (presence of a papule) are not specific indicators of skin malignancy. Lesions with uniform pigmentation are more likely to be benign. Petechiae are tiny red spots due to bleeding under the skin and are not typically associated with skin cancer. Papules are small raised bumps that can have various causes, not necessarily cancerous. Therefore, choice C is the most concerning finding for skin cancer based on asymmetry, prompting further evaluation and possible biopsy.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
- A. Remove the outer cannula carefully during cleaning.
- B. Use tracheostomy covers when outdoors.
- C. Use sterile technique when performing tracheostomy care at home.
- D. Cleanse mist with full-strength hydrogen peroxide.
Correct Answer: C
Rationale: The correct answer is C: Use sterile technique when performing tracheostomy care at home. This is crucial to prevent infections and ensure the client's safety. Sterile technique involves maintaining a clean environment, using sterile gloves, and sterile supplies to reduce the risk of introducing harmful microorganisms. Removing the outer cannula during cleaning (A) can increase the risk of accidental dislodgement and should only be done when necessary by a healthcare professional. Tracheostomy covers (B) are used to provide warmth and moisture, not necessarily for infection control. Cleansing mist with full-strength hydrogen peroxide (D) is too harsh and can damage the skin and mucous membranes.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This action ensures proper fit and compression without causing restriction or compromising circulation. A: Assisting the client into a prone position is not necessary for applying the sleeves. B: Placing the sleeve with the opening at the knee is incorrect as it should be at the top of the leg. D: Setting the ankle pressure at 65 mm Hg is not specified for thigh-length sleeves and may not be appropriate.