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The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
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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 preparing to care for a child with anemia from a culture that is different from the nurse's. Which is the best way to address the cultural needs of the child and family when the child is admitted to the health care facility?
- A. Address only those issues that directly affect the nurse's care of the child.
- B. Ask questions, and explain to the family why the questions are being asked.
- C. Explain that cultural practices need to be discontinued during hospitalization.
- D. Ignore cultural needs because they are not important to health care professionals.
Correct Answer: B
Rationale: When caring for individuals from a different culture, it is important to ask questions about their specific cultural needs and means of treatment. An understanding of the family's beliefs and health practices is essential to successful interventions for that particular family. Eliminate the options that ignore the cultural beliefs and values of the client.
A client with the diagnosis of mania is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention should the nurse include in the plan of care before seclusion?
- A. Ask the client if she understands why the seclusion is necessary.
- B. Remain silent because verbal interaction would be too stimulating.
- C. Tell the client that she will be allowed to come out when she can behave.
- D. Inform the client that she is being secluded to help regain her self-control.
Correct Answer: D
Rationale: Seclusion is a process in which a client is placed alone in a specially designed room for protection and close supervision. This client is removed to a nonstimulating environment as a result of her behavior. Options 1, 2, and 3 are nontherapeutic actions. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion.
A client with arterial leg ulcers tells the nurse, 'I'm so discouraged. I have had this pain for more than a year now. The pain never seems to go away. I can't do anything, and I feel as though I'll never get better.' The nurse determines that which is the priority client concern?
- A. Fatigue
- B. Uneasiness
- C. Chronic pain
- D. An acute illness
Correct Answer: C
Rationale: The major focus of the client's complaint is the experience of pain. Pain that has a duration of more than 3 months is defined as chronic pain and does not indicate an acute illness. There are no data in the question that indicate fatigue or uneasiness.
A client awaiting surgery for the removal of a pancreatic mass shares with the nurse concerns about not waking up after receiving the anesthesia. Which therapeutic response is most appropriate for the nurse to make to the client?
- A. This is a very common concern.
- B. Tell me what makes you feel concerned about the anesthesia.
- C. I had surgery a year ago and was afraid of the same thing. I did just fine.
- D. You have the best anesthesiologist in this hospital. There is no need to be scared.
Correct Answer: B
Rationale: This client is concerned about surgery and is expressing fear about the anesthesia. The therapeutic response to the client is the one that encourages the client to express her or his concerns. Option 1 is a stereotypical response. Option 3 avoids the client's concern and focuses on the nurse's personal experience. Option 4 also avoids the client's concern.