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A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, “Go away! No one can help me.†Which of the following responses should the nurse make?
- A. Everything will be ok.
- B. I will come back later and we can talk.
- C. Why are you crying?
- D. Do you think crying will help?
Correct Answer: B
Rationale: The correct answer is B: "I will come back later and we can talk." This response shows empathy, respect for the client's autonomy, and a willingness to provide support without being intrusive. By offering to come back later, the nurse acknowledges the client's feelings and demonstrates a willingness to engage in a supportive conversation when the client is ready.
Choice A is incorrect because it dismisses the client's feelings without offering meaningful support. Choice C may come off as confrontational and put the client on the defensive. Choice D is dismissive and lacks empathy, potentially making the client feel unsupported. Overall, choice B is the best response as it respects the client's feelings and allows for a supportive conversation at a later time.
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A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first?
- A. Disconnect the tube from the wall suction.
- B. Perform hand hygiene and don gloves.
- C. Observe the amount and color of drainage.
- D. Verify provider order to discontinue the tube.
Correct Answer: D
Rationale: The correct answer is D: Verify provider order to discontinue the tube. This is the first step the nurse should take before removing the NG tube to ensure that the removal is in line with the provider's instructions. Removing the tube without a valid order can lead to complications. Disconnecting the tube from wall suction (A) should be done after verifying the order. Performing hand hygiene and donning gloves (B) is important but can be done after verifying the order. Observing the amount and color of drainage (C) is important but should come after verifying the order.
A nurse is collecting data from a client's skin. Which of the following actions should the nurse take to assess skin turgor?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size red or purple spots.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: The correct answer is D: Grasp a fold of skin on the client's forearm or near the sternum. This method assesses skin turgor by evaluating how quickly the skin returns to its normal position after being pinched. Adequate skin turgor indicates good hydration status, as hydrated skin will snap back promptly. If the skin remains elevated or "tents," it may indicate dehydration. Choice A involves palpation, which assesses skin temperature and texture but not turgor. Choice B involves assessing edema, not skin turgor. Choice C describes petechiae, which are indicative of bleeding disorders. Overall, choice D is the most appropriate for assessing skin turgor accurately.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?
- A. I am thinking of getting a second opinion.
- B. I am hoping this will help relieve my discomfort.
- C. This is making me stronger every day.
- D. This is not working, and I plan to stop treatment.
Correct Answer: B
Rationale: Palliative care focuses on symptom relief, and the statement reflects an understanding of this goal.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." Mammograms are recommended for women starting at age 40 to screen for breast cancer. Annual mammograms help detect any abnormalities early, improving the chances of successful treatment. Choice A is incorrect as skin checks should be done annually. Choice C is incorrect as the first colonoscopy is usually recommended at age 50. Choice D is incorrect as there is no standard screening for uterine cancer every 2 years.
A nurse is caring for a client who has diabetes mellitus and had a below-the-knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
- A. When I look in the mirror, all I see is a person without a leg.
- B. I have not always made good choices in life. I deserve to lose my leg.
- C. If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
- D. No matter how hard I work in physical therapy, I can't seem to make any progress.
Correct Answer: A
Rationale: A body image disturbance is reflected in the client's negative perception of their physical self.