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The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
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A nurse on the mental health unit is preparing a presentation on suicide for a group of student nurses. Which information would be included in this presentation? Select all that apply.
- A. Chronic pain or serious, disabling illness has little to no effect on suicide risk.
- B. Hispanic Americans attempt suicide at a greater rate than whites or African Americans.
- C. Suicide risk declines sharply once antidepressant medication has been taken for a few weeks.
- D. White males over the age of 80 are at the greatest risk among all age, race, and gender groups.
- E. Threatened suicide and/or gestures should be taken seriously and handled by trained professionals.
Correct Answer: D,E
Rationale: Chronic pain and serious illness increase suicide risk, making A incorrect. Data shows Hispanic Americans have lower suicide rates than whites, making B incorrect. Antidepressants may initially increase risk, making C incorrect. White males over 80 have the highest suicide rates, and all threats should be taken seriously, making D and E correct.
A client who has never been hospitalized before and is in a hospital room with a roommate is anxious and having trouble initiating a stream of urine. Knowing that there is no pathological reason for this difficulty, which nursing interventions should be included when assisting the client? Select all that apply.
- A. Catheterizing the client
- B. Running tap water in the sink
- C. Assisting the client to a commode behind a closed curtain
- D. Instructing the client to pour warm water over the perineum
- E. Closing the bathroom door and instructing the client to pull the call bell when done
Correct Answer: B,D,E
Rationale: A lack of privacy is a key issue that may inhibit the ability of the client to void in the absence of known pathology. Using a commode behind a curtain may inhibit voiding for some individuals, especially with a roommate present. The use of a bathroom is preferable, and this may be supplemented with the use of running water or pouring water over the perineum, as needed. Catheterization is not a nursing intervention and presents a risk of infection. If noninvasive techniques do not work, then the primary health care provider may prescribe that the client be catheterized.
A client awaiting surgery for the removal of a pancreatic mass shares with the nurse concerns about not waking up after receiving the anesthesia. Which therapeutic response is most appropriate for the nurse to make to the client?
- A. This is a very common concern.
- B. Tell me what makes you feel concerned about the anesthesia.
- C. I had surgery a year ago and was afraid of the same thing. I did just fine.
- D. You have the best anesthesiologist in this hospital. There is no need to be scared.
Correct Answer: B
Rationale: This client is concerned about surgery and is expressing fear about the anesthesia. The therapeutic response to the client is the one that encourages the client to express her or his concerns. Option 1 is a stereotypical response. Option 3 avoids the client's concern and focuses on the nurse's personal experience. Option 4 also avoids the client's concern.
The nurse provides care for a client diagnosed with bulimia. Which nursing action is most helpful in determining what precipitates the client'sEating disorder?
- A. Observe the family communication patterns at a monitored mealtime.
- B. Distract the client at mealtimes.
- C. Assign the client a food/feelings/thoughts action journal.
- D. Ask the client to write a history of eating behaviors.
Correct Answer: C
Rationale: A food/feelings/thoughts journal helps identify triggers and patterns associated with binge-purge behaviors, providing insight into precipitants. Observing family dynamics is useful but less direct, and distraction or history-writing are less focused on current triggers.
The nurse is leading a crisis intervention group comprising high school students who have experienced the recent death of a classmate who committed suicide. The students are experiencing disbelief as they review the details of the suicide. Which should be the initial therapeutic action by the nurse?
- A. Ask how the students recovered from a death event in the past.
- B. Reinforce the students' ability to work through this death event.
- C. Inquire about the students' perception of their classmate's suicide.
- D. Reinforce the students' sense of growth through this death experience.
Correct Answer: C
Rationale: It is essential to determine the students' views. Inquiring about the students' perception of the suicide will specifically identify the appraisal of the suicide and the meaning of the perception. Although option 1 is exploratory, it does not address the 'here-and-now' appraisal in terms of the classmate's suicide. Although the nurse is interested in how students have coped in the past, this inquiry should not be the most immediate assessment. Options 2 and 4 are attempts to foster students' self-esteem. Such an approach is premature at this point.