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A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.
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After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovering process after discharge. Which available resource should the nurse plan to tell the client and family about to best address their concerns?
- A. The United Way
- B. The client's local church
- C. The American Cancer Society Reach for Recovery
- D. The American Heart Association Mended Hearts Club
Correct Answer: D
Rationale: Most clients and families benefit from knowing that there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon, cardiologist, and nurse; cardiac rehabilitation programs; and community support groups such as the American Heart Association Mended Hearts Club, which is a nationwide program with local chapters. The United Way provides a wide variety of services to people who may not otherwise be able to afford them. The library normally does not provide resources for coping with the recuperative process. The American Cancer Society Reach for Recovery helps women recover after mastectomy.
The nurse is caring for a terminally ill woman who is dying from diagnosed breast cancer. The nurse should know which client behavior is characteristic of anticipatory grieving?
- A. Discusses thoughts and feelings related to loss
- B. Has prolonged emotional reactions and outbursts
- C. Verbalizes unrealistic goals and plans for the future
- D. Ignores untreated medical conditions that require treatment
Correct Answer: A
Rationale: The nurse can determine the client's stage of anticipatory grief by observing the client's behavior. The remaining options are examples of dysfunctional grieving.
The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.)
- A. Sing or talk to the client throughout the activity.
- B. Expose only one area at a time while bathing.
- C. Complete the bath as quickly as possible.
- D. Organize all supplies before starting the bath.
- E. Bathe the client slowly and explain each action.
Correct Answer: A,B,D,E
Rationale: For a client with dementia, appropriate bathing strategies include: (A) Singing or talking to provide comfort and reduce anxiety; (B) Exposing only one area to maintain dignity and prevent chilling; (D) Organizing supplies to minimize disruption; (E) Bathing slowly and explaining actions to reduce confusion. Completing the bath quickly (C) may increase agitation and is not appropriate.
The nurse was assigned to the mental health care area from another area in the facility. A client accuses the nurse of being a terrorist with poisonous pills when the nurse is preparing medications. Which response by the nurse is best?
- A. I am not a terrorist.
- B. Is it your feeling that I am trying to poison you?
- C. This is your medication, which you have to take now.
- D. I am a nurse from another unit in this hospital.
Correct Answer: B
Rationale: Reflecting the client’s feelings validates their emotions and opens therapeutic communication without confrontation, which is critical for a client with possible paranoia. Denying, insisting, or explaining may escalate distrust.
An 11-year-old child scheduled for a diagnostic procedure will have an intravenous line inserted and will receive an intramuscular injection. Which form of communication should the nurse use in preparing the child for the procedure?
- A. Reassuring the child by introducing the equipment used
- B. Teaching the parents so that they can explain everything to the child
- C. Telling the child not to worry because the doctors take care of everything
- D. Using pictures, concrete words, and demonstrations to describe what will happen
Correct Answer: D
Rationale: Using pictures, concrete words, and demonstrations is the most effective way to communicate with an 11-year-old child about a medical procedure, as it aligns with their developmental stage and helps them understand what to expect. Option 1 may not fully address the child's need for clear explanations. Option 2 relies on parents, which may not be as direct or effective. Option 3 dismisses the child's concerns and is nontherapeutic.