Nokea
The nurse implements which de-escalation techniques with a client who is extremely angry and exhibiting increasingly agitated behavior?
- A. Avoid verbal struggles.
- B. Provide clear options to the client.
- C. Use therapeutic touch on the client's shoulder.
- D. Maintain both the client's self-esteem and dignity.
- E. Establish what the client considers to be her or his needs.
- F. Use a firm and assertive tone of voice when speaking to the client.
Correct Answer: A,B,D,E
Rationale: When the client is angry and exhibits increasingly agitated behavior, the nurse should employ de-escalation techniques to prevent client violence and assaultive behaviors. These techniques include assessing the situation, using a calm and clear tone of voice when communicating with the client, remaining calm, avoiding verbal struggles, presenting clear options to the client, and maintaining the client's self-esteem and dignity. The nurse should establish what the client considers to be her or his need and maintain a large personal space (touching the client could increase agitation).
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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.
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.
On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. Which response would the nurse provide?
- A. It seems that you've changed your mind about rooming in.
- B. I think you're having difficulty caring for the baby.
- C. All right. I'll inform the other nurses of your decision.
- D. You must be tired. I'll bring the baby back at feeding time.
Correct Answer: A
Rationale: Stating that it seems that the client has changed her mind opens communication and allows the client to verbalize her thoughts and feelings. This response acknowledges the client's request without being judgmental. Stating that the client is having difficulty caring for the baby is presumptuous and could make the client defensive. Informing other nurses of the client's decision without exploring the reasons behind it may not address the client's concerns. Although the client may be tired, assuming this without further discussion may overlook the client's true feelings and needs, hindering effective communication and support.
The nurse observes the parent of an adult client crying in the waiting area. The parent says to the nurse, 'My father died of meningitis decades ago. Now my child may die of the same thing.' Which is the best initial response by the nurse?
- A. The outlook for meningitis is better now than it was then.
- B. I can have the chaplain come speak with you if you like.
- C. This must be bringing back a lot of memories.
- D. Not necessarily. You can't make that assumption.
Correct Answer: C
Rationale: Acknowledging that the situation may evoke memories validates the parent’s emotional distress and opens communication. Offering facts, a chaplain, or dismissal does not address the immediate emotional need.
The nurse notes that a toddler has numerous bruises, a possible fractured left humerus, and several lacerations. Which action will the nurse take first?
- A. Report findings to Child Protective Services.
- B. Ask the parents what caused the injuries.
- C. Review the client's previous medical record.
- D. Observe the interaction between the parents and client.
Correct Answer: A
Rationale: Suspected child abuse, indicated by multiple bruises, a possible fracture, and lacerations, requires immediate reporting to Child Protective Services as mandated by law to ensure the child's safety. This takes precedence over other actions to initiate protective measures promptly.