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The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern?
- A. Lack of knowledge about COPD
- B. Difficulty coping related with a situational crisis
- C. Negative self-image because of neurological deficit
- D. Restricted verbal communication because of a physical barrier
Correct Answer: D
Rationale: A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options.
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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.
The nurse on the cardiac unit notes that a client recovering from a myocardial infarction appears worried and irritable. The client says, 'I am worried about my business. I run a restaurant and am used to working 70 hours a week. I am worried about whether I will be able to handle the stress once I am back there.' Which response by the nurse is best?
- A. Give the client a list of complementary therapies related to relaxation and say, 'Pretend this is a menu. Which of these would you like to order for yourself?'
- B. You might find it interesting to attend the cardiac cooking class the dietitian gives before you are discharged.
- C. Who is supposed to be taking care of the restaurant while you are here in the hospital?
- D. Hand the client the television control and say, 'Sometimes when I have a lot on my mind, I watch a movie. It makes me feel better.'
Correct Answer: A
Rationale: Providing a list of relaxation therapies directly addresses the client’s stress concerns and empowers them to choose coping strategies, aligning with their expressed worries about returning to a high-stress job. Other options are less relevant to stress management.
An 11-year-old child scheduled for a diagnostic procedure will have an intravenous line inserted and will receive an intramuscular injection. Which form of communication should the nurse use in preparing the child for the procedure?
- A. Reassuring the child by introducing the equipment used
- B. Teaching the parents so that they can explain everything to the child
- C. Telling the child not to worry because the doctors take care of everything
- D. Using pictures, concrete words, and demonstrations to describe what will happen
Correct Answer: D
Rationale: Using pictures, concrete words, and demonstrations is the most effective way to communicate with an 11-year-old child about a medical procedure, as it aligns with their developmental stage and helps them understand what to expect. Option 1 may not fully address the child's need for clear explanations. Option 2 relies on parents, which may not be as direct or effective. Option 3 dismisses the child's concerns and is nontherapeutic.
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.
The nurse is caring for a terminally ill woman who is dying from diagnosed breast cancer. The nurse should know which client behavior is characteristic of anticipatory grieving?
- A. Discusses thoughts and feelings related to loss
- B. Has prolonged emotional reactions and outbursts
- C. Verbalizes unrealistic goals and plans for the future
- D. Ignores untreated medical conditions that require treatment
Correct Answer: A
Rationale: The nurse can determine the client's stage of anticipatory grief by observing the client's behavior. The remaining options are examples of dysfunctional grieving.