Nokea
The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
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The nurse is caring for a client with a diagnosis of terminal cancer of the throat. The family tells the nurse that they have spoken to the primary health care provider regarding taking their loved one home. The nurse plans to coordinate discharge planning. Which service would be most supportive to the client and the family?
- A. Hospice care
- B. The American Cancer Society
- C. The American Lung Association
- D. Local religious and social organizations
Correct Answer: A
Rationale: Hospice care provides an environment that emphasizes caring rather than curing; the emphasis is on palliative care. One of the major goals of hospice care is that clients be free of pain and other symptoms that do not allow them to maintain a quality life. An interdisciplinary approach is used. Although the remaining options may be helpful, they are not the most supportive of the options provided.
A client with the diagnosis of hyperparathyroidism states to the nurse, 'I can't stay on this diet. It is too difficult for me.' Which therapeutic response by the nurse is best when intervening in this situation?
- A. Why do you think you find this diet plan difficult to adhere to?
- B. It really isn't difficult to stick to this diet. Just avoid milk products.
- C. You are having a difficult time staying on this plan. Let's discuss this.
- D. It is very important that you stay on this diet to avoid forming renal calculi.
Correct Answer: C
Rationale: By paraphrasing the client's statement, the nurse can encourage the client to verbalize emotions. The nurse also sends feedback to the client that the message was understood. An open-ended statement or question such as this prompts a thorough response from the client. Option 1 requests information that the client may not be able to express. Option 2 devalues the client's feelings. Option 4 gives advice, which blocks communication.
A client has a hip fracture repair with a prosthetic implant placed. On the day after the implant, the nurse finds the client surrounded by papers from his briefcase and planning a phone meeting. The nurse plans to discuss activities with the client and should base the discussion on which information?
- A. Rest is an essential component of bone healing.
- B. Setting limits on a client's behavior is a mandated nursing role.
- C. Not keeping up with his job will increase the client's stress level.
- D. Involvement in his job will keep the client from becoming bored.
Correct Answer: A
Rationale: Rest is an essential component of bone healing, particularly after a hip fracture repair with a prosthetic implant. Engaging in work-related activities, such as planning a phone meeting, may interfere with the necessary rest and recovery process. Options 2, 3, and 4 do not prioritize the physiological need for rest and healing, which is critical at this stage of recovery.
The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is reporting insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse should recognize these complaints to be indications of which disorder?
- A. Phobia
- B. Dissociative disorder
- C. Obsessive-compulsive disorder
- D. Post-traumatic stress disorder (PTSD)
Correct Answer: D
Rationale: PTSD is precipitated by events that are overwhelming, unpredictable, and sometimes life threatening. Typical symptoms of PTSD include difficulty concentrating, sleep disturbances, intrusive recollections of the traumatic event, hypervigilance, and anxiety. These symptoms are not characteristic of the disorders noted in options 1, 2, and 3.
The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?
- A. Support in maintaining a sense of control
- B. Less pain and anxiety than with a normal labor
- C. A sense of satisfaction regarding her quick labor
- D. Fewer fears regarding the effect of labor on the newborn infant
Correct Answer: A
Rationale: The client experiencing a precipitous labor may have more difficulty maintaining control because of the abrupt onset and quick progression of the labor. This may be very different from previous labor experiences; therefore, the client needs support from the nurse to understand and adapt to the rapid progression. The contractions often increase in intensity very quickly, which adds to the client's pain, anxiety, and lack of control. The client may also have an increased amount of concern about the effect of the labor on the newborn infant. A lack of control over the situation in combination with increased pain and anxiety can result in a decreased level of satisfaction with the labor and delivery experience.