Nokea
The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety?
- A. Staying with the client
- B. Distracting the client with television
- C. Interpreting the arterial blood gas report
- D. Encouraging the client to cough and breathe deeply
Correct Answer: A
Rationale: Staying with the client has a twofold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after the application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax, which would result in a sudden decline in respiratory status and a mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Option 2 is nontherapeutic. Interpreting the arterial blood gas report and promoting coughing and deep breathing have no immediate benefits for the client who is in distress.
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The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?
- A. The client is experiencing delusions of messianic grandeur.
- B. The client believes that the world is ending on a specific date.
- C. The client is experiencing persistent pain after the resolution of herpes zoster.
- D. The client is experiencing blindness without an identified physical cause.
Correct Answer: D
Rationale: Conversion disorder involves physical symptoms, like blindness, without a medical cause, often linked to psychological stress. Blindness without a physical cause is a classic example, unlike delusions or unrelated pain.
A client reports having difficulty concentrating and outbursts of anger, as well as feeling 'keyed up' all the time. The client reveals that the behaviors began soon after witnessing the murder of a good friend. The nurse should suspect which stressor before communicating with the client?
- A. Social phobia
- B. Panic disorder
- C. Post-traumatic stress disorder (PTSD)
- D. Obsessive-compulsive disorder (OCD)
Correct Answer: C
Rationale: PTSD is a response to an event that would be markedly distressing to almost anyone. Characteristic symptoms include a sustained level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of anger. Panic disorders and social phobia are characterized by a specific fear of an object or situation. OCD involves some repetitive thoughts or behaviors.
A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.
After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovering process after discharge. Which available resource should the nurse plan to tell the client and family about to best address their concerns?
- A. The United Way
- B. The client's local church
- C. The American Cancer Society Reach for Recovery
- D. The American Heart Association Mended Hearts Club
Correct Answer: D
Rationale: Most clients and families benefit from knowing that there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon, cardiologist, and nurse; cardiac rehabilitation programs; and community support groups such as the American Heart Association Mended Hearts Club, which is a nationwide program with local chapters. The United Way provides a wide variety of services to people who may not otherwise be able to afford them. The library normally does not provide resources for coping with the recuperative process. The American Cancer Society Reach for Recovery helps women recover after mastectomy.
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
- A. Do you have a death wish?'
- B. Do you wish your life was over?'
- C. Do you ever think about ending it all?'
- D. Do you have any thoughts of killing yourself?'
Correct Answer: D
Rationale: A lethality assessment requires direct communication between the client and the nurse concerning the client's intent. It is important to provide a question that is directly related to lethality. Euphemisms should be avoided.