Nokea
The nurse discovers a hospice client has expired. The family members are assembled in the facility's waiting room. Which of the following statements by the nurse would be the most appropriate?
- A. My condolences on the passing of your family member. You may visit him if you wish.
- B. I will give you some time to spend with your loved one. Let me know if you need anything.
- C. You should view your loved one as a way of saying farewell.
- D. It would be best if you not view your loved one just yet.
Correct Answer: B
Rationale: This statement offers support, gives the family autonomy, and invites further communication, which is sensitive and appropriate.
You may also like to solve these questions
During an office visit, a prenatal client diagnosed with mitral stenosis states being under a lot of stress lately. During the examination, the client questions the nurse about the assessment and behaves anxiously. Which is the appropriate nursing action at this time?
- A. Tell the client not to worry.
- B. Refer the client to a counselor.
- C. Assume that the client's anxiety will lessen when the assessment is finished.
- D. Explain the purpose of the nurse's actions and answer the client's questions.
Correct Answer: D
Rationale: In the prenatal cardiac client, stress should be reduced as much as possible. The client should be provided with honest and informed answers to questions to help alleviate unnecessary fears and emotional stress. Explaining the purpose of nursing actions will assist with decreasing the stress level of the client. The remaining options are nontherapeutic because they neglect to deal with the client's concerns.
The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action should the nurse include in the plan of care?
- A. Encouraging the child to confront the abuser
- B. Providing a care environment that fosters trust
- C. Teaching the child to make wise choices when faced with possible abuse
- D. Reinforcing for the child that not all adults are capable of abusing children
Correct Answer: B
Rationale: Providing a safe and trusting environment is critical for a child who has experienced physical abuse, as it helps the child feel secure and supported, facilitating emotional healing. Encouraging the child to confront the abuser is inappropriate and could be traumatic, especially for a young child. Teaching the child to make wise choices in potentially abusive situations places an unrealistic burden on the child, who may not have the capacity to protect themselves. Reinforcing that not all adults are abusive is less immediate and does not directly address the child's need for a safe and trusting care environment.
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a diagnosis of major depressive disorder. Which assessment findings should the nurse identify as expected short-term side effects of ECT that do not require notifying the primary health care provider?
- A. Confusion
- B. Memory loss
- C. Hypertension
- D. Disorientation
- E. Heart palpitations
Correct Answer: A,B,D
Rationale: The major expected side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure or presence of heart palpitations would not be anticipated side effects and would be causes for concern. If hypertension or presence of heart palpitations occurred after ECT, the primary health care provider should be notified.
A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea-anxiety-dyspnea cycle?
- A. Guided imagery and limiting fluids
- B. Relaxation and breathing techniques
- C. Biofeedback and coughing techniques
- D. Distraction and increased dietary carbohydrates
Correct Answer: B
Rationale: Relaxation and breathing techniques are effective in interrupting the dyspnea-anxiety-dyspnea cycle by calming the client and improving respiratory efficiency. These techniques help reduce anxiety, which can exacerbate dyspnea, and promote controlled breathing to enhance oxygenation. Guided imagery may be helpful but limiting fluids is unrelated to managing dyspnea or anxiety. Biofeedback and coughing techniques are not primarily indicated for this cycle. Distraction and increased dietary carbohydrates do not directly address the cycle and may not provide immediate relief.
A client diagnosed with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. On the basis of which understanding about this procedure should the nurse offer emotional support to the client?
- A. This problem may decrease the client's life expectancy.
- B. The client is likely to be in excruciating pain after surgery.
- C. The client will probably have chronic dyspnea after the surgery.
- D. Chest tubes will be in place after surgery, and the healing process is slow.
Correct Answer: D
Rationale: The client undergoing decortication to treat empyema needs ongoing support from the nurse. This is especially true because the client will have chest tubes in place after surgery, and these must remain until the former pus-filled space is completely obliterated. This may take some time, and it may be discouraging to the client. Progress is monitored by chest x-ray. This information supports that the remaining options are not accurate.