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The nurse is bathing a client when the client begins to cry. Which action by the nurse is therapeutic at this time?
- A. Continue bathing the client and say nothing.
- B. Stop the bath, cover the client, and sit with the client.
- C. Stop the bath, cover the client, and allow the client private time.
- D. Call the primary health care provider to report the signs of depression.
Correct Answer: B
Rationale: If a client begins to cry, the nurse should stay with the client and let the client know that it is all right to cry. The nurse should ask the client what the client is thinking or feeling at the time. By continuing the bath or by leaving the client, the nurse appears to be ignoring the client's feelings. Crying alone is not necessarily an indication of depression, and calling the primary health care provider is a premature action.
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A client and her infant have been diagnosed as being positive for human immunodeficiency virus (HIV). When the mother is observed crying, the nurse determines that which intervention will meet the client's initial needs?
- A. Discussing how the mother was exposed to HIV
- B. Sitting quietly with the mother as she talks and cries
- C. Describing the progressive stages and treatments of HIV
- D. Calling an HIV counselor to make an appointment for the mother and infant
Correct Answer: B
Rationale: This client has just received devastating news and needs to have someone present with her as she begins to cope with this issue. The nurse needs to sit and actively listen while the mother talks and cries. Examining the mother and describing the progression and treatment of HIV is not appropriate for this stage of coping. Calling an HIV counselor may be helpful, but it is not what the client needs initially.
An older couple was emotionally despondent when their home was severely damaged by flooding. When planning for the couple's initial needs, what intervention should the community health nurse implement?
- A. Contacting their families
- B. Attending to their emotional needs
- C. Arranging for the repair of their home
- D. Attending to their basic physiological needs
Correct Answer: D
Rationale: The question asks about the first thing that the nurse needs to consider when planning for the rescue and relocation of these older residents. The initial concerns of community health are always attending to people's basic needs of food, shelter, and clothing. Contacting family, addressing emotional needs, and arranging for home repairs are needs that may be addressed as needed after physiological needs are met.
A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time?
- A. Remaining with the client
- B. Placing the client in a quiet room
- C. Teaching the client deep-breathing exercises
- D. Encouraging the expression of feelings and concerns
Correct Answer: A
Rationale: If the client is left alone with severe anxiety, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
The nurse has an established relationship with the family of a client whose death is imminent. Which intervention should the nurse focus on in order to help the family most effectively cope with this experience?
- A. Limiting time in the client's room to promote privacy
- B. Providing education regarding coping mechanisms to use
- C. Identifying spiritual measures that work best for dying clients
- D. Answering questions clearly and providing resources as requested
Correct Answer: D
Rationale: Maintaining effective and open communication among family members affected by death and grief is important to facilitate decision making and effective coping. The nurse maintains and enhances communication and preserves the family's sense of self-direction and control effectively by answering questions clearly and providing information and resources for decision making as requested by the family. Isolating the family from the client by limiting time in the client's room is inappropriate. The nurse should not provide education about coping mechanisms for family members to use because coping mechanisms directed by the nurse are unlikely to be as effective as the methods that the individuals choose for themselves. Identifying spiritual measures that work best for the dying client generalizes and does not reflect individualized care.
When a client is dead on arrival (DOA) to the emergency department, the family states that they do not want an autopsy performed. Which statement should the nurse make in response to the family?
- A. Autopsies are mandatory for clients who are DOA.'
- B. Federal law requires autopsies for clients who are DOA.'
- C. The medical examiner makes the decision about autopsies.'
- D. I will make sure the medical examiner is aware of your request.'
Correct Answer: D
Rationale: The nurse should notify the medical examiner or the coroner when a family wishes to avoid having an autopsy on a deceased family member. Normally the medical examiner will honor the family request unless there is a state law requiring the autopsy. Depending on the state, it is not mandatory for every client who is DOA to have an autopsy. However, many states require an autopsy in specific circumstances, including sudden death, a suspicious death, and death within 24 hours of admission to the hospital. Autopsy is not a requirement under federal law.