Nokea
The home care nurse is caring for a client with lung cancer with acute cancer pain. Which is the most appropriate way to assess the client's pain?
- A. The client's pain rating
- B. The nurse's impression of the client's pain
- C. Verbal and nonverbal clues from the client
- D. Pain relief after appropriate nursing intervention
Correct Answer: A
Rationale: The client's perception of pain is the hallmark of pain assessment. Usually noted by the client's rating on a scale of 1 to 10, the assessment is documented and followed with appropriate medical and nursing interventions. The nurse's impression and the verbal and nonverbal clues are subjective data. Pain relief after intervention is appropriate but relates to evaluation.
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The rehabilitation nurse witnessed a postoperative client who had a coronary artery bypass graft and his spouse arguing after a rehabilitation session. Which would be the most appropriate therapeutic statement for the nurse to make to identify the feelings of the client?
- A. You seem upset.'
- B. Oh, don't let this get you down.'
- C. It will seem better tomorrow. Now smile.'
- D. You shouldn't get upset. It'll affect your heart.'
Correct Answer: A
Rationale: Acknowledging the client's feelings without inserting your own values or judgments is a method of therapeutic communication. Therapeutic communication techniques assist with the flow of communication, and they always focus on the client. Option 1 is an open-ended statement that allows the client to verbalize, which gives the nurse a direction or clarification of the client's true feelings. The remaining options do not encourage verbalization by the client.
A client diagnosed with severe preeclampsia is admitted to the hospital. The client is a student at a local college and insists on continuing her studies while in the hospital, despite being instructed to rest. The client studies approximately 10 hours a day and has numerous visits from fellow students, family, and friends. Which intervention should the nurse use to best assist the client with promoting rest?
- A. Ask her why she is not complying with the prescription for bed rest.
- B. Develop a routine with the client to balance her studies and her rest needs.
- C. Include a significant other in helping the client understand the need for bed rest.
- D. Instruct the client that the health of the baby is more important than her studies at this time.
Correct Answer: B
Rationale: Option 2 involves the client in the decision-making process. In options 1 and 4 the nurse is judging the client's choices and asking probing questions; this will cause a breakdown in communication. Option 3 persuades the client's significant other to disagree with the client's actions. This could cause problems with the relationship between the client and the significant other, and it could also cause conflict in the client's communication with the health care workers.
The nurse is caring for a client who has been diagnosed with schizophrenia. The client is unable to speak, although there is no known pathological dysfunction. Based on this information, the nurse determines that the client is experiencing which type of dysfunctional communication?
- A. Mutism
- B. Verbigeration
- C. Pressured speech
- D. Poverty of speech
Correct Answer: A
Rationale: Mutism is the absence of verbal speech. The client does not communicate verbally despite an intact physical and structural ability to speak. Verbigeration is the purposeless repetition of words or phrases. Pressured speech refers to a rapidity of speech that reflects the client's racing thoughts. Poverty of speech involves diminished amounts of speech or monotonic replies.
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct Answer: B
Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose × Volume on hand) / Dose on hand). In this case, it would be (4 mg × 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.
A 9-year-old child is hospitalized in traction for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development?
- A. Providing a music player
- B. Tutoring to keep the child up with schoolwork
- C. Providing a phone for calling family and friends
- D. Placing computer games, a television, and videos at the bedside
Correct Answer: B
Rationale: The developmental task of the school-age child is industry versus inferiority. The child achieves success by mastering skills and knowledge. Maintaining schoolwork provides for accomplishment and prevents feelings of inferiority that may be caused by lagging behind the rest of the class. The other options provide diversion and are of lesser importance for a child of this age.