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The nurse is admitting a client who is to undergo ureterolithotomy. Which should the nurse assess in order to determine if the client is ready for surgery?
- A. The need for a visit from a support group
- B. The knowledge of postoperative activities
- C. An understanding of the surgical procedure
- D. Expected outcomes of the surgical procedure
- E. Feelings or anxieties about the surgical procedure
Correct Answer: B,C,D,E
Rationale: Ureterolithotomy is the removal of a calculus from the ureter using either a flank or abdominal incision. The client should have an understanding of the same items as are required for any surgery, including knowledge of the procedures, the expected outcome, the postoperative routines, and any expected discomfort. The client should also be assessed for any concerns or anxieties before surgery. Because no urinary diversion is created during this procedure, the client has no need for a visit from a member of a support group.
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A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, 'I know I need it, but I'm not sure this surgery is a great idea.' Which nursing response should best help the nurse assess the client's preoperative concerns?
- A. How does your family feel about the surgery?
- B. Has anyone taught you about the procedure yet?
- C. You sound extremely worried. Has anyone told you that the technology is really quite safe?
- D. You sound uncertain about the procedure. Can you tell me more about what has you concerned?
Correct Answer: D
Rationale: Anxiety is common in the client with the need for pacemaker insertion. This can be related to a fear of life-threatening dysrhythmias or of the surgical procedure. Option 4 is the correct choice because it is open-ended and uses clarification as a communication technique to explore the client's concerns. Option 1 is not indicated because it asks about the family and deflects attention away from the client's concerns. Options 2 and 3 are closed-ended and are not exploratory.
A client diagnosed with diabetes mellitus has expressed frustration with learning the diabetic regimen and insulin administration. Which should be the initial action by the home care nurse?
- A. Attempt to identify the cause of the frustration.
- B. Call the primary health care provider to discuss the client's problem.
- C. Offer to administer the insulin on a daily basis until the client is ready to learn.
- D. Continue with teaching, knowing that the client will overcome any frustrations.
Correct Answer: A
Rationale: The home care nurse must determine what is causing the client's frustration. The issue needs to be addressed by the nurse before involving the provider. Administering the insulin provides only a short-term solution. Continuing to teach may only further block the learning process.
The nurse is leading a crisis intervention group comprising high school students who have experienced the recent death of a classmate who committed suicide. The students are experiencing disbelief as they review the details of the suicide. Which should be the initial therapeutic action by the nurse?
- A. Ask how the students recovered from a death event in the past.
- B. Reinforce the students' ability to work through this death event.
- C. Inquire about the students' perception of their classmate's suicide.
- D. Reinforce the students' sense of growth through this death experience.
Correct Answer: C
Rationale: It is essential to determine the students' views. Inquiring about the students' perception of the suicide will specifically identify the appraisal of the suicide and the meaning of the perception. Although option 1 is exploratory, it does not address the 'here-and-now' appraisal in terms of the classmate's suicide. Although the nurse is interested in how students have coped in the past, this inquiry should not be the most immediate assessment. Options 2 and 4 are attempts to foster students' self-esteem. Such an approach is premature at this point.
A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, 'I'm not sure I can take any more of this treatment.' Which therapeutic response should the nurse make to the client?
- A. Let's just put the tube down, so that you can get well.'
- B. If you don't have this tube put down, you will just continue to vomit.'
- C. You are feeling tired and frustrated with your recovery from surgery?'
- D. It is your right to refuse any treatment. I'll notify the primary health care provider.'
Correct Answer: C
Rationale: In option 3, the nurse uses empathy. Empathy, comprehending, and sharing a client's frame of reference are important components of the nurse-client relationship. This assists clients with expressing and exploring feelings, which can lead to problem-solving. The other options are examples of barriers to effective communication, including option 1, which is stereotyping; option 2, which is defensiveness; and option 4, which is showing disapproval.
A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of bipolar disorder?
- A. Sometimes I'm ready to take on the world, but other times I'm too tired to get out of bed.
- B. I need to check and then recheck all the kitchen appliances several times to make sure they are off before I feel comfortable leaving my home.
- C. My neighbors hold sacrificial rites in their backyard.
- D. I keep on patrol all night so the enemy won't invade my home and hurt me or my family.
Correct Answer: A
Rationale: This statement describes mood swings between mania and depression, characteristic of bipolar disorder.