Nokea
Before inserting a peripheral intravenous (IV) catheter into a preoperative client, the nurse notes that the client's muscles are tense and the client is fidgeting with the bed sheet, stating that she does not understand why she has to have the IV. Which statement should the nurse first verbalize to the client?
- A. This will be finished before you know it.'
- B. Inserting the IV does not hurt very much.'
- C. The IV adds needed fluid into your bloodstream.'
- D. The IV catheter is an 18-gauge angiocatheter, which is small.'
Correct Answer: C
Rationale: In option 3 the nurse uses simple terms to clearly inform the client about the IV's purpose. Option 1 is an unethical statement for the nurse to make because the information is incorrect. Avoiding the client's feelings in option 2 blocks client communication regarding justifiable fears and feelings related to the IV insertion. Option 4 is an unsuitable statement because the client potentially would not understand the word 'angiocatheter.'
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What is a common reason why clients abuse alcohol?
- A. To blunt reality
- B. To precipitate euphoria
- C. To promote social interaction
- D. To stimulate the central nervous system
Correct Answer: A
Rationale: Clients often abuse alcohol to blunt reality. Alcohol, by depressing the central nervous system and distorting or altering reality, can reduce anxiety. It is not primarily used to precipitate euphoria; instead, it may lead to mood swings, impaired judgment, and aggressive behavior. While alcohol can be used as a social lubricant, individuals with alcohol use disorder often drink in isolation. Moreover, excessive alcohol consumption can result in inappropriate and aggressive behaviors that hinder social interactions. It's important to note that alcohol is a depressant, unlike stimulants such as amphetamines and cocaine.
The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?
- A. The client is going through a grieving period.
- B. The client talks as if another person is affected.
- C. The client is willing to learn techniques to adapt.
- D. The client recognizes the reality and becomes anxious.
Correct Answer: D
Rationale: In this scenario, the client's recognition of the reality and subsequent anxiety cues the nurse that the client is in the withdrawal phase of adjusting to the change in body image. During this phase, the client may refuse to discuss the change and may use withdrawal as a coping mechanism. The grieving period typically occurs during the acknowledgement phase, where the client and family come to terms with the change in physical appearance. Initially, shock and depersonalization may lead the client to talk as if another person is affected by the change. Finally, in the rehabilitation stage, the client is ready to learn techniques to adapt to the change, such as through the use of prosthetics or modifying lifestyles and goals.
When attempting to incorporate the Latino client's cultural background into the plan of care, which consideration is the most important?
- A. Socioeconomic considerations regarding hospitalization
- B. The meaning and attention the client places on the future
- C. The client's need to control care to ensure desired outcomes
- D. Inclusion of the family in the plan of care with the client's permission
Correct Answer: D
Rationale: The most important consideration when incorporating the Latino client's cultural background into the plan of care is the inclusion of the family in the care plan with the client's permission. In Latino cultures, family plays a vital role, and there is a strong emphasis on family support during challenging times. This support can positively impact the client's health outcomes and overall well-being. Socioeconomic status, although relevant, does not carry more weight than usual in healthcare decisions. Latino clients typically focus on the present rather than the future, and they often attribute outcomes to external factors like fate or divine intervention. While the client's need for control is important, involving the family aligns more closely with the cultural values and preferences of Latino clients.
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.
What feeling is likely to result from withdrawn behavior?
- A. Anger
- B. Paranoia
- C. Loneliness
- D. Boredom
Correct Answer: C
Rationale: Withdrawn behavior involves avoiding social interactions and isolating oneself. This isolation can lead to feelings of loneliness as the individual lacks connection and companionship. While anger or paranoia may contribute to withdrawal, loneliness is a common emotional consequence of prolonged social isolation. Boredom may also arise from withdrawal if meaningful activities and social engagements are reduced.