Nokea
After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client's need to ambulate?
- A. What is it about getting out of bed that concerns you?'
- B. If you are afraid of the pain, I can give you medication to help.'
- C. If you don't get up and start walking, your recovery will take much longer.'
- D. Being dependent on others must be a depressing for an active person like yourself.'
Correct Answer: A
Rationale: Early ambulation during the postoperative period is very important to a client's health and recovery, but many different factors may be contributing to the client's refusal to ambulate as prescribed. Asking an open-ended question that encourages a discussion about getting out of bed is the best option available to allow the nurse to facilitate the client's plan of care. Pain may be a concern for the client, but again, the nurse is making an unfounded assumption. Although it is true that the recovery might be prolonged by not ambulating and the client may be depressed, these statements make assumptions about the reason the client is refusing to comply with the plan of care.
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When responding to the call bell, the nurse finds the client lying on the floor beside the bed. After a thorough assessment and appropriate care, the nurse completes an incident report. How should the incident be described in the report?
- A. The client fell out of bed and was found on the floor.
- B. The client fell while climbing over the bed's side rails.
- C. The client was found lying on the floor beside the bed.
- D. The client was restless and fell while getting out of bed.
Correct Answer: C
Rationale: The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only option that describes the facts as observed by the nurse. All the remaining options are interpretations of the situation and are not factual data as observed by the nurse.
The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, 'I don't think that this ECT will be helpful, especially since it makes people's memory worse.' What form of communication should the nurse implement to address the family member's concern?
- A. Ask other family members and the client if they think that ECT makes people worse.
- B. Immediately reassure the client and family that ECT will help and that the memory loss is only temporary.
- C. Involve the family member in a dialog to ascertain how the family member arrived at this conclusion.
- D. Reinforce with the client and the family member that depression causes more memory impairment than ECT.
Correct Answer: C
Rationale: Involving the family member in a dialog allows the nurse to understand their concerns and provide accurate information about ECT, addressing misconceptions about memory loss. Option 1 shifts focus away from the family member's concern, option 2 provides premature reassurance without exploring the concern, and option 4 makes an assumption about the cause of memory impairment without addressing the family member's specific worry.
A client diagnosed with delirium anxiously states, 'Look at the spiders on the wall.' Which response by the nurse addresses the client's concerns therapeutically?
- A. Would you like me to kill the spiders for you?'
- B. While there may be spiders on the wall, they are not going to hurt you.'
- C. I know that you are frightened, but I do not see any spiders on the wall.'
- D. You are having a hallucination; I'm sure there are no spiders in this room.'
Correct Answer: C
Rationale: When hallucinations are present, the nurse should reinforce reality with the client while acknowledging the client's feelings as the correct option does. Eliminate options 1, 2, and 4 because they do not reinforce reality but rather support the legitimacy of the hallucination or that reinforces reality but does not address the client's feelings.
A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears?
- A. Open-ended questions and silence
- B. Offering personal opinions about the need to eat
- C. Verbalizing reasons why the client may choose not to eat
- D. Focusing on self-disclosure of the nurse's own food preferences
Correct Answer: A
Rationale: Open-ended questions and silence are strategies that are used to encourage clients to discuss their feelings in a descriptive manner. Options 2 and 3 are not helpful to the client because they do not encourage the expression of personal feelings. Option 4 is not a client-centered intervention.
The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse-client relationship. Which intervention is representative of this phase of the relationship?
- A. The nurse and client determine the contract for time.
- B. The client is encouraged to make use of all services depending on need.
- C. The client begins to identify with the nurse, and trust and rapport are maintained.
- D. The nurse focuses on facilitating the therapeutic expression of the client's feelings.
Correct Answer: A
Rationale: In the orientation (introductory phase) of the therapeutic nurse-client relationship, the client and nurse meet and determine the contract for time, such as how often to meet, the length of the meetings, and when termination is anticipated to occur. Utilizing services, identification with the nurse, and expression of feelings are appropriate for the working phase of the therapeutic nurse-client relationship.