Nokea
The nurse is caring for a client who is having surgery the next morning. The client says, 'I'm really scared about surgery. I've never been put to sleep before and I'm afraid I might not wake up.' Which response by the nurse is the most therapeutic?
- A. Why are you worried about such a minor procedure?
- B. We can call the doctor and cancel the surgery if you would prefer.
- C. It's normal to be afraid of something new like surgery. Tell me how you feel.
- D. Don't worry, you have a really good doctor and he will see to it that nothing goes wrong.
Correct Answer: C
Rationale: Acknowledging fear as normal and encouraging the client to express feelings (C) is therapeutic, promoting open communication. Minimizing concerns (A), suggesting cancellation (B), or offering false reassurance (D) dismisses the client's emotions.
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A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, 'I am so afraid my baby is going to die.' Which response by the nurse to the client is best?
- A. Finding out your baby has a serious health problem must be painful.
- B. How does your husband feel about this problem?
- C. How is your baby doing now?
- D. What you need to do is to focus on the present.
Correct Answer: A
Rationale: Acknowledging the client’s pain validates their fear and opens therapeutic communication, supporting emotional processing. Asking about others, focusing on the fetus’s status, or directing focus to the present dismisses the client’s expressed fear.
A client who is in halo traction states to the visiting nurse, 'I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is.' Which therapeutic response should the nurse make to the client?
- A. If I were you, I would have had the surgery rather than suffer like this.
- B. No one ever gets used to that thing! It's horrible. Many of our sports people who are in it complain vigorously.
- C. Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around.
- D. Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think?
Correct Answer: C
Rationale: In option 3, the nurse employs empathy and reflection. The nurse then offers a strategy for problem-solving, which helps increase the peripheral vision of the client in halo traction. In option 1, the nurse undermines the client's faith in the medical treatment being employed by giving advice that is insensitive and unprofessional. In option 2, the nurse provides a social response that contains emotionally charged language that could increase the client's anxiety. In option 4, the nurse uses excessive questioning and gives advice, which is nontherapeutic.
A pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, 'What have I done to cause this? If only I could live my life over.' Considering this statement, which concern should the nurse identify for the client?
- A. Injury to the fetus because of maternal distress
- B. Low self-esteem because of pregnancy complications
- C. Lack of understanding about diabetic self-care during pregnancy
- D. Poorly perceived body image caused by complications of pregnancy
Correct Answer: B
Rationale: The client is putting the blame for the diabetes on herself, thus lowering her self-esteem. She is expressing fear and grief. There are no data in the question to support the problems in options 1 and 4. Client lack of understanding is important to consider, but not at this time because the client will not be able to comprehend information in her current state.
A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief should the nurse monitor the client for?
- A. Stating a fear of the future and unknown
- B. Engaging in periods of weeping or raging
- C. Expressing anger at the medical professionals
- D. Expressing a feeling of unreality and disbelief
- E. Expressing a desire to run away from the situation
- F. Stating that he knows all he needs to know about his condition
Correct Answer: A,B,C,D,E
Rationale: Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear.
The nurse is caring for a client who presented to the ED with a blood alcohol level of 208 mg/dL. The client states that his last drink was about 8 hours ago. He exhibits coarse tremors of the hands, anxiety, and elevated blood pressure. Which of the following would the nurse expect if his condition progresses to withdrawal delirium? Select all that apply.
- A. fever of 100°F to 103°F
- B. increased appetite, especially for sweets
- C. excessive sleeping of 14 hours or more daily
- D. onset of delirium 12 to 24 hours after the last drink
- E. onset of delirium 48 to 72 hours after the last drink
- F. disorientation and fluctuating levels of consciousness
Correct Answer: A,E,F
Rationale: Withdrawal delirium typically includes fever, disorientation, and fluctuating consciousness, with onset 48-72 hours after the last drink. Increased appetite or excessive sleeping are not typical.