Nokea
A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
You may also like to solve these questions
A nurse is caring for a client whose belongings were lost in a hurricane. The client says, 'What's the use in starting over? It will probably happen again.' Which of the following responses should the nurse make?
- A. I am sure everything will work out.'
- B. It appears you are feeling hopeless.'
- C. It is probably not as bad as you think.'
- D. I would not worry about what can't be changed.'
Correct Answer: B
Rationale: Acknowledging feelings of hopelessness is therapeutic and encourages the client to express emotions.
A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
- A. Brachial
- B. Carotid
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: The correct answer is B: Carotid. Checking the carotid pulse bilaterally simultaneously can lead to a temporary decrease in blood flow to the brain, potentially causing dizziness or fainting. It is important to assess one carotid pulse at a time to ensure adequate blood supply to the brain. Checking the brachial, femoral, and popliteal pulses bilaterally at the same time is safe as it does not pose a risk of compromising blood flow to critical organs.
A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
- A. Move body parts rapidly through the movements.
- B. Support extremities above and below joints.
- C. Stretch the body part just beyond the existing range of motion.
- D. Continue moving body parts if muscle spasticity occurs.
Correct Answer: B
Rationale: The correct answer is B: Support extremities above and below joints. This is because supporting the extremities above and below the joints helps to maintain proper alignment and stability during passive range of motion exercises, preventing injury and ensuring effective movement. Moving body parts rapidly (choice A) can cause muscle strain or injury. Stretching the body part beyond existing range (choice C) can lead to muscle or ligament damage. Continuing movement if spasticity occurs (choice D) can exacerbate muscle tightness. This is why choice B is the most appropriate action to take during passive range of motion exercises.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?
- A. Ask the client to perform a return demonstration of insulin injection.
- B. Review the action of insulin therapy.
- C. Explore the client's feelings about dietary modifications.
- D. Have a family member practice blood glucose monitoring using a glucometer.
Correct Answer: C
Rationale: The correct answer is C because exploring the client's feelings about dietary modifications focuses on the affective domain of learning, which involves emotions, attitudes, and values. By understanding the client's feelings, the nurse can address any concerns, fears, or resistance the client may have towards changing their diet. This approach helps to create a supportive and empathetic environment for the client to embrace necessary dietary changes.
Regarding the incorrect choices:
A: Asking the client to perform a return demonstration of insulin injection focuses on psychomotor skills, not affective learning.
B: Reviewing the action of insulin therapy focuses on cognitive learning, not affective learning.
D: Having a family member practice blood glucose monitoring is not directly related to addressing the client's emotional response to dietary modifications.
A nurse is collecting data from a client who reports persistent vomiting, dizziness, palpitations, and numbness and tingling in his fingers and toes and around his mouth. The nurse notes the client's respirations are slow and shallow. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic alkalosis. The client's symptoms of vomiting, dizziness, palpitations, numbness and tingling, along with slow and shallow respirations, indicate a loss of hydrogen ions (H⁺) and chloride ions (Cl⁻) due to prolonged vomiting, leading to metabolic alkalosis. Vomiting causes a loss of stomach acid (HCl), leading to an increase in blood pH. Respiratory acidosis (C) results from inadequate ventilation, causing CO₂ retention and increased carbonic acid in the blood. Respiratory alkalosis (D) is characterized by hyperventilation and decreased CO₂ levels. Metabolic acidosis (A) involves a decrease in blood pH due to an excess of metabolic acids or a loss of bicarbonate ions.