Nokea
A postoperative client displays signs of anxiety when the nurse explains that the intravenous (IV) line will need to be discontinued as a result of an infiltration. Which appropriate statement should the nurse make to the client?
- A. This is usually a painless experience. It is nothing to worry about.'
- B. I'm sure it will be a real relief for you just as soon as I discontinue this IV for good.'
- C. Just relax and take a deep breath. This procedure will not take long, and it will be over soon.'
- D. I can see that you're anxious. Removal of the IV shouldn't be painful, but the IV will need to be restarted in another location.'
Correct Answer: D
Rationale: The correct option addresses the client's anxiety and honestly informs the client that the IV may need to be restarted. This option uses the therapeutic technique of giving information, and it also acknowledges the client's feelings. Although discontinuing an IV is a painless experience, it is not therapeutic to tell a client not to worry. Option 2 does not acknowledge the client's feelings, and it does not tell the client that an infiltrated IV may need to be restarted. Option 3 does not address the client's feelings.
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A client has been diagnosed with terminal cancer and is using opioid analgesics for pain relief. Which action by the home care nurse would best allay the client's anxiety about becoming addicted to the pain medication?
- A. Encouraging the client to hold off as long as possible between doses of pain medication
- B. Encouraging the client to take lower doses of medications even though the pain is not well controlled
- C. Explaining to the client that the fears are justified but should be of no concern during the final stages of care
- D. Explaining to the client that addiction rarely occurs in individuals who are taking medication appropriately to relieve pain
Correct Answer: D
Rationale: Clients who are on opioid analgesics often have well-founded fears about addiction, even in the face of pain. The nurse has the responsibility to provide correct information about the likelihood of addiction while still maintaining adequate pain control. Addiction is rare for individuals who are taking medication to relieve pain. Allowing the client to be in pain, as in options 1 and 2, is not acceptable nursing practice. Option 3 is only partially correct in that it acknowledges the client's fear.
Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?
- A. I'm so angry that this happened to me.
- B. I really don't want to live my life like this.
- C. I'm definitely not looking forward to going home.
- D. I don't know if I can make all these major adjustments to my life.
Correct Answer: B
Rationale: It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness.
The parents of a newborn infant diagnosed with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these statements, the nurse identifies which concern for the parents?
- A. Inability to cope with change
- B. Anger about lost opportunities
- C. Trouble adjusting to a child born with medical issues
- D. Depression associated with the birth of a child with defects
Correct Answer: D
Rationale: Depression is a normal part of the grieving process. It is a reaction to practical implications related to loss. Although the parents may have trouble adjusting and have anger, the best answer is to address their depression and sadness. The grief process includes intellectual and emotional responses and behaviors by which individuals and families work through the process of modifying their self-concepts on the basis of the perception of potential loss. Characteristics include expressions of sorrow and distress at the potential loss.
A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, 'My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?' Which therapeutic response should the nurse make to the client's daughter?
- A. Tell me what you think you did wrong.'
- B. Maybe we can keep your father in the hospital for a while longer to give you a rest.'
- C. You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care.'
- D. An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed.'
Correct Answer: D
Rationale: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.
A 12-year-old client is seen in the health care clinic. During the assessment, which finding would suggest to the nurse that the client is experiencing a disruption in the development of self-concept?
- A. The child has many friends.
- B. The child has a part-time babysitting job.
- C. The child has an intimate relationship with a significant other.
- D. The child enjoys playing chess and mastering new skills with this game.
Correct Answer: C
Rationale: The formation of an intimate relationship would not be expected until young adulthood. Friends are important and appropriate for members of this age group. A sense of industry is appropriate for this age group, and it may be exhibited by the child having a part-time job. The increase in self-esteem associated with skill mastery is an important part of development for the school-age child.