Nokea
A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention?
- A. Sitting quietly with the client
- B. Telling the client that crying is not helpful
- C. Suggesting that the client play a board game
- D. Recommending how the client can change this situation
Correct Answer: A
Rationale: The correct therapeutic nursing intervention in this situation is sitting quietly with the client. This approach conveys empathy, acceptance, and a willingness to listen, which can help the teenager feel supported and understood. It is important for the nurse to create a safe space for the client to express their emotions without judgment. Telling the client that crying is not helpful dismisses their feelings and can hinder the therapeutic relationship. Suggesting a board game as a distraction may prevent the client from fully exploring and addressing their emotions about the issue. Recommending how the client can change the situation may be premature at this stage, as the priority is to provide emotional support and establish trust before delving into problem-solving.
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A client is having a panic attack. Which nursing intervention has priority for this client?
- A. have the client recount a positive childhood memory
- B. provide the client with a glass of water
- C. tell the client to take deep breaths
- D. ask the client to identify the source of his anxiety
Correct Answer: C
Rationale: Deep breathing helps reduce hyperventilation and physiological symptoms during a panic attack, making it the priority intervention.
Which of the following examples indicates that the nurse is giving recognition as a form of therapeutic communication?
- A. You need to take your medicine now, Adam.
- B. Jill, your father is trying to make amends with you.
- C. The physician wants to meet with you and your husband, Amy.
- D. Linda, you brushed your hair this morning.
Correct Answer: A
Rationale: Recognition is a form of therapeutic communication in which the nurse points out a positive aspect of the client's behavior. Noting that a client brushed her hair herself indicates that the nurse recognizes the client's attempts at self-care. This recognition shows the client that the nurse is paying attention and may be open to further communication. Choices A, B, and C do not demonstrate recognition. Choice A focuses on a directive statement, Choice B involves informing the client about a situation without acknowledging their actions, and Choice C informs the client about a meeting without providing recognition for any behavior.
The nurse observes the parent of an adult client crying in the waiting area. The parent says to the nurse, 'My father died of meningitis decades ago. Now my child may die of the same thing.' Which is the best initial response by the nurse?
- A. The outlook for meningitis is better now than it was then.
- B. I can have the chaplain come speak with you if you like.
- C. This must be bringing back a lot of memories.
- D. Not necessarily. You can't make that assumption.
Correct Answer: C
Rationale: Acknowledging that the situation may evoke memories validates the parent’s emotional distress and opens communication. Offering facts, a chaplain, or dismissal does not address the immediate emotional need.
The nurse provides care to a school-aged client diagnosed with terminal cancer. Which nursing action offers support to the family and client during the terminal stages of the illness?
- A. Encourage the family to avoid any reference to death or dying.
- B. Decrease the amount of time the client spends with siblings.
- C. Assure the family that they will receive support after discharge.
- D. Limit the information and explanations given to the client.
Correct Answer: C
Rationale: Assuring the family of ongoing support after discharge provides emotional reassurance and practical guidance during a difficult time. Avoiding death discussions, limiting sibling time, or withholding information may hinder coping and closure.
A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests that the client is in the denial about his medical condition?
- A. Requests a sedative for sleep at 10:00 pm
- B. Expresses a hesitancy to leave the hospital
- C. Consumes 25% of foods and fluids given for supper
- D. Walks up and down three flights of stairs unsupervised
Correct Answer: D
Rationale: Ignoring activity limitations and avoiding lifestyle changes are signs of the denial stage. Walking three flights of stairs should be a supervised activity during this phase of the recovery process. Option 1 is an appropriate client action on the evening before discharge. Option 2 may be a manifestation of anxiety or fear rather than denial. Option 3 is a manifestation of depression rather than denial.