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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.
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A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
- A. Encourage clients to establish a timeline for their own grieving process.
- B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
- C. Assist clients in identifying ways suicide could have been prevented.
- D. Discourage clients from sharing negative aspects of their relationship with the deceased persons.
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This strategy is important in supporting clients dealing with the aftermath of a family member's suicide as it acknowledges the significant impact on family dynamics. It allows clients to explore and process the changes within the family system and develop coping mechanisms. This approach fosters open communication and mutual support within the group.
Choice A is incorrect because grief is a highly individualized process and establishing a timeline may not be helpful or realistic for everyone. Choice C is incorrect as it may inadvertently place blame on the deceased and lead to feelings of guilt among clients. Choice D is incorrect as it can hinder the healing process by suppressing valid emotions and preventing the group from exploring their feelings openly.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client’s refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. This is the priority because understanding the client's concerns or barriers to using the spirometer allows the nurse to address them effectively, promote the client's recovery, and prevent complications such as pneumonia. Requesting a respiratory therapist (A) can be helpful, but understanding the client's reasons comes first. Documenting refusal (C) is important but does not address the immediate need to assess and intervene. Administering pain medication (D) may provide temporary relief but does not address the root cause of refusal.
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.
nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork belowi. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
- D. D
Correct Answer:
Rationale: Correct Answer: B
Rationale: Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation. Auscultating at location B (lower anterior chest wall) allows for better detection of crackles in the bases of the lungs where pneumonia commonly affects. This area corresponds to the lower lobes where consolidation occurs, leading to crackles. Auscultating at other locations (A, C, D) may not yield clear crackle sounds associated with pneumonia.
Summary of other choices:
A (Location A - upper anterior chest wall): Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation.
C (Location C - middle anterior chest wall): Crackles in pneumonia are not typically heard in the middle lung fields.
D (Location D - upper lateral chest wall): Crackles in pneumonia are not typically heard in the upper lateral chest wall.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often, since it is not controlling my pain.
- B. Breathing faster will help me keep my mind off of the pain.
- C. It might help me to listen to music while trying to sleep.
- D. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C: "It might help me to listen to music while trying to sleep." This answer indicates that the client understands the preoperative teaching about pain management, as distraction techniques such as listening to music can help manage pain perception. Listening to music can be a non-pharmacological method to alleviate pain and promote relaxation. Choices A and D indicate a lack of understanding as they suggest inappropriate responses to pain. Choice B suggests a distraction technique but not the most effective one. Choices E, F, and G are not provided, but based on the context, they would likely be irrelevant or incorrect in the context of pain management.