Nokea
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
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The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, 'Became angry and physically abusive.' Which action does the nurse take first?
- A. Encourage the client to verbalize feelings.
- B. Assess the client for physical trauma.
- C. Provide a list of shelters appropriate for the situation.
- D. Assist the client to identify a support system.
Correct Answer: B
Rationale: Assessing for physical trauma is the priority to identify injuries requiring immediate medical attention, ensuring the client's safety. Verbalizing feelings, providing shelter lists, and identifying support systems are important but secondary to physical assessment.
A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care?
- A. Attend a support group.
- B. Cease dwelling on the negative.
- C. Reach out for help to face this fear.
- D. Share her feelings with her partner.
Correct Answer: D
Rationale: Talking to the client about sharing her feelings with her husband directly addresses the subject of the question. Encouraging the client to start a support group will not address the client's immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client's concern.
A postoperative client displays signs of anxiety when the nurse explains that the intravenous (IV) line will need to be discontinued as a result of an infiltration. Which appropriate statement should the nurse make to the client?
- A. This is usually a painless experience. It is nothing to worry about.'
- B. I'm sure it will be a real relief for you just as soon as I discontinue this IV for good.'
- C. Just relax and take a deep breath. This procedure will not take long, and it will be over soon.'
- D. I can see that you're anxious. Removal of the IV shouldn't be painful, but the IV will need to be restarted in another location.'
Correct Answer: D
Rationale: The correct option addresses the client's anxiety and honestly informs the client that the IV may need to be restarted. This option uses the therapeutic technique of giving information, and it also acknowledges the client's feelings. Although discontinuing an IV is a painless experience, it is not therapeutic to tell a client not to worry. Option 2 does not acknowledge the client's feelings, and it does not tell the client that an infiltrated IV may need to be restarted. Option 3 does not address the client's feelings.
A client has a hip fracture repair with a prosthetic implant placed. On the day after the implant, the nurse finds the client surrounded by papers from his briefcase and planning a phone meeting. The nurse plans to discuss activities with the client and should base the discussion on which information?
- A. Rest is an essential component of bone healing.
- B. Setting limits on a client's behavior is a mandated nursing role.
- C. Not keeping up with his job will increase the client's stress level.
- D. Involvement in his job will keep the client from becoming bored.
Correct Answer: A
Rationale: Rest is an essential component of bone healing, particularly after a hip fracture repair with a prosthetic implant. Engaging in work-related activities, such as planning a phone meeting, may interfere with the necessary rest and recovery process. Options 2, 3, and 4 do not prioritize the physiological need for rest and healing, which is critical at this stage of recovery.
The nurse is assessing a client to determine the client's adjustment to presbycusis. Which indicates successful adaptation by the client to this problem?
- A. Proper use of a hearing aid
- B. Denial of a hearing impairment
- C. Withdrawal from social activities
- D. Reluctance to answer the telephone
Correct Answer: A
Rationale: Presbycusis occurs as part of the aging process; it is a progressive sensorineural hearing loss. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Some clients may not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid.