Nokea
A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, 'I'm not sure I can take any more of this treatment.' Which therapeutic response should the nurse make to the client?
- A. Let's just put the tube down, so that you can get well.'
- B. If you don't have this tube put down, you will just continue to vomit.'
- C. You are feeling tired and frustrated with your recovery from surgery?'
- D. It is your right to refuse any treatment. I'll notify the primary health care provider.'
Correct Answer: C
Rationale: In option 3, the nurse uses empathy. Empathy, comprehending, and sharing a client's frame of reference are important components of the nurse-client relationship. This assists clients with expressing and exploring feelings, which can lead to problem-solving. The other options are examples of barriers to effective communication, including option 1, which is stereotyping; option 2, which is defensiveness; and option 4, which is showing disapproval.
You may also like to solve these questions
A client diagnosed with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears to be normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. Which information should the nurse initially provide to the client?
- A. It is very likely that the client will need dialysis within 5 to 10 years.
- B. One kidney is adequate to meet the needs of the body, as long as it has normal function.
- C. There is absolutely no chance of the client needing dialysis because of the nature of the surgery.
- D. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.
Correct Answer: B
Rationale: Fears about having only one functioning kidney are common among clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs as long as it has normal function. This information supports that the remaining options are inaccurate.
A client diagnosed with moderate dementia is prescribed oral anticoagulant therapy while hospitalized. The nurse identifies which discharge scenario as being the best support system for successful anticoagulant therapy monitoring?
- A. The client has a home health aide coming to the house for 9 weeks.
- B. The client was going to stay with a daughter in the daughter's home indefinitely.
- C. The client was going to have blood work drawn in the home by a local laboratory.
- D. The client has a good friend living next door who would take the client to the doctor.
Correct Answer: B
Rationale: The client taking anticoagulant therapy should be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply with the medication regimen, the continuance of the regimen should be questioned. Option 2 provides a direct support system. Clients may need support systems in place to enhance compliance with therapy. Option 1 facilitates reminding the client to take the medication, option 3 facilitates blood work only, and option 4 facilitates medical care.
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
The nurse provides care for four clients who require teaching about their medical conditions. The nurse assesses that which client is the most ready to learn?
- A. A client who woke up from a nap recently, just ate a snack, and is sitting up in bed.
- B. A client who was just informed of a cancer diagnosis by the health care provider.
- C. A client recovering from a stroke who has returned from physical therapy.
- D. A client who received pain medication 5 minutes ago for relief of discomfort.
Correct Answer: A
Rationale: A client who is rested, nourished, and alert (after a nap and snack, sitting up) is in an optimal state for learning. Recent diagnosis, fatigue from therapy, or recent pain medication may impair readiness to learn.
A postpartum client with a diagnosis of gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, 'Do I have to worry about this diabetes anymore?' Which is the most appropriate response by the nurse?
- A. Your blood glucose level is within normal limits now, so you will be all right.'
- B. You will have to worry about the diabetes only if you become pregnant again.'
- C. You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus.'
- D. When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your life.'
Correct Answer: C
Rationale: The client is at risk for developing gestational diabetes with each pregnancy. The client also has an increased risk for developing diabetes mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing diabetes mellitus; however, with proper care, it may not develop.