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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A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item, that was previously used to minimize the client's anxiety, should now be limited?
- A. Radio
- B. Television
- C. Family visitors
- D. Antianxiety medications
Correct Answer: D
Rationale: Antianxiety medications and opioid analgesics are used cautiously in the client who is being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The client may exhibit anxiety during the weaning process for a variety of reasons; therefore, distractions such as radio, television, and visitors are still very useful.
Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?
- A. I'm so angry that this happened to me.
- B. I really don't want to live my life like this.
- C. I'm definitely not looking forward to going home.
- D. I don't know if I can make all these major adjustments to my life.
Correct Answer: B
Rationale: It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness.
A client has been diagnosed with terminal cancer and is using opioid analgesics for pain relief. Which action by the home care nurse would best allay the client's anxiety about becoming addicted to the pain medication?
- A. Encouraging the client to hold off as long as possible between doses of pain medication
- B. Encouraging the client to take lower doses of medications even though the pain is not well controlled
- C. Explaining to the client that the fears are justified but should be of no concern during the final stages of care
- D. Explaining to the client that addiction rarely occurs in individuals who are taking medication appropriately to relieve pain
Correct Answer: D
Rationale: Clients who are on opioid analgesics often have well-founded fears about addiction, even in the face of pain. The nurse has the responsibility to provide correct information about the likelihood of addiction while still maintaining adequate pain control. Addiction is rare for individuals who are taking medication to relieve pain. Allowing the client to be in pain, as in options 1 and 2, is not acceptable nursing practice. Option 3 is only partially correct in that it acknowledges the client's fear.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
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.