Nokea
The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
- A. Help the client express fears.
- B. Assess the nature of the client's fears.
- C. Help the client identify coping mechanisms that were successful in the past.
- D. Document verbal and nonverbal expressions of fear and other significant data.
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.
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The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond?
- A. Do you want me to call your daughter?'
- B. Can you tell me a little about what has you so upset?'
- C. Try not to be so upset. Psychological stress is bad for your heart.'
- D. I understand how you feel. I'd cry, too, if I had a major heart attack.'
Correct Answer: B
Rationale: Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information should the nurse incorporate when formulating a response to the family member's statement?
- A. A brain tumor presents with few sights/symptoms.
- B. It is true that brain tumors are easily recognizable.
- C. Brain tumors are never detected until very late in their course.
- D. The signs/symptoms of a brain tumor may be easily attributed to another cause.
Correct Answer: D
Rationale: Signs and symptoms of a brain tumor vary depending on location, and they may easily be attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and changes in intellectual abilities or personality. Seizures occur in some clients. These symptoms can be easily attributed to other causes. The family requires support to assist them during the normal grieving process. Options 1, 2, and 3 are inaccurate statements.
The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?
- A. Monitor vital signs every 15 minutes.
- B. Administer bromocriptine as prescribed.
- C. Administer the haloperidol as prescribed.
- D. Assess the client's level of consciousness.
Correct Answer: B
Rationale: The symptoms suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to haloperidol. Administering bromocriptine, if prescribed, is the priority to reverse NMS. Monitoring, continuing haloperidol, or assessing consciousness delays critical intervention.
A client who is to be discharged to home with a temporary colostomy states to the nurse, 'I know I've changed this thing once, but I just don't know how I'll do it by myself when I'm home alone. Can't I stay here until the surgeon puts it back?' Which therapeutic response should the nurse make to best deal with the client's concerns?
- A. This is only temporary, but with your level of anxiety you need to hire a nurse companion until your surgery.'
- B. So you're saying that, although you've practiced changing your colostomy bag once, you don't feel comfortable on your own yet?'
- C. Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you'll have to fight it out with them.'
- D. Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you're feeling more comfortable.'
Correct Answer: D
Rationale: The client is expressing feelings of fear and helplessness. Option 4 assists with meeting this client's needs. Option 1 provides information that the client already knows and then problem-solves by using a client-centered action, which would probably overwhelm the client. Option 2 is restating, but this response could cause the client to feel more helpless because the client's fears are reflected back to the client. Option 3 provides what is probably accurate information, but the words 'just to practice' can be interpreted by the client as belittling.