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A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends's behavior shows that they aren't true friends
Correct Answer: C
Rationale: It is important for the nurse to listen and show interest as the client expresses their feelings in this situation. The client's emotional distress is a valid response to feeling abandoned by friends and family during a difficult time. By providing a supportive and empathetic presence, the nurse can help the client feel valued and understood, promoting emotional well-being and potentially increasing the client's sense of comfort and trust in the healthcare setting. This approach validates the client's feelings and fosters therapeutic communication, which is crucial in providing holistic care to individuals with complex health needs such as AIDS and Pneumocystis carinii pneumonia. It is essential to acknowledge and address the client's emotional needs in addition to their physical care.
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What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)?
- A. Explain how SIDS could have been predicted and prevented. TestBankWorld.org
- B. Interview parents in depth concerning the circumstances surrounding the child's death.
- C. Discourage parents from making a last visit with the infant.
- D. Make a follow-up home visit to parents as soon as possible after the child's death.
Correct Answer: D
Rationale: One of the most important nursing responsibilities when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS) is to provide ongoing support and care to the grieving parents. Making a follow-up home visit as soon as possible after the child's death allows the nurse to offer emotional support, assess the parents' well-being, provide information on coping strategies, and refer them to appropriate resources such as counseling services or support groups. This visit also enables the nurse to address any questions or concerns the parents may have, validate their feelings of grief, and help them navigate the difficult grieving process. By being present and available to the family during this challenging time, the nurse can help them feel supported and cared for as they cope with the tragic loss of their infant.
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: Arcus senilis is a condition characterized by a white or gray ring forming around the cornea and does not typically cause visual problems. It is a common and benign condition often seen in older adults. On the other hand, glaucoma, macular degeneration, and cataracts are all eye conditions that can significantly affect vision and lead to visual impairments in older adults. Therefore, in planning safe care for the older adult, the nurse should recognize that Arcus senilis would not cause visual problems unlike the other conditions mentioned.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: A diagnosis of breast cancer is confirmed through a biopsy, which involves removing a sample of tissue or cells from the lump in the breast and examining it under a microscope. Fine needle aspiration is a minimally invasive procedure where a thin needle is used to remove cells from the lump for examination. This diagnostic method allows for the confirmation of breast cancer by analyzing the cells for signs of malignancy. While breast self-examinations, mammography, and chest x-rays are important tools for detecting breast abnormalities, they are not definitive in confirming a diagnosis of breast cancer.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: In caring for a client with bronchogenic carcinoma, the highest priority nursing diagnosis would be Ineffective airway clearance related to obstruction by a tumor or secretions. This is crucial because any blockage in the airway can lead to serious respiratory complications, such as respiratory distress or respiratory failure. Ensuring effective airway clearance is essential to maintain adequate oxygenation and ventilation for the client. Addressing this priority nursing diagnosis promptly can help prevent potential life-threatening situations and promote optimal respiratory function for the client.
\What should the nurse teach an older client with TIA?
- A. Not to worry about the symptoms that are part of the normal aging process
- B. To admit oneself to a rehabilitation center or a nursing home for rehabilitation
- C. To comply with the medication regimen
- D. To observe any changes in the nails and skin
Correct Answer: C
Rationale: The nurse should teach an older client with a transient ischemic attack (TIA) to comply with the medication regimen. TIA is a warning sign of a potential stroke, and medication compliance is crucial in reducing the risk of a future stroke. Medications prescribed after a TIA may include blood thinners, antiplatelet agents, antihypertensives, and cholesterol-lowering drugs. It is essential for the client to take these medications as directed by their healthcare provider to prevent further cardiovascular events. Compliance with the medication regimen plays a significant role in managing the risk factors associated with stroke and promoting long-term health and well-being.