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The nurse obtains an electrocardiogram (ECG) rhythm strip for an adult client who is anxious about the results. The ECG shows that the heart rate is 90 beats per minute. Which statement should the nurse make to the client to relieve anxiety?
- A. The rate is normal.
- B. There is no need to worry.
- C. A slower heart rate is preferred.
- D. Medication specific to the problem will be prescribed.
Correct Answer: A
Rationale: A normal adult resting pulse rate ranges between 60 and 100 beats per minute; therefore, the rate is normal. The nurse would not tell a client not to worry. Options 3 and 4 indicate that the ECG is abnormal.
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A client diagnosed with cardiomyopathy stops eating, takes long naps, and turns away from the nurse when the nurse talks to the client. The nurse should make which interpretation about this behavior?
- A. The client is depressed.
- B. The client is noncompliant.
- C. The client has intractable pain.
- D. The client is unable to tolerate activity.
Correct Answer: A
Rationale: Depression is a common problem related to clients who have long-term and debilitating illnesses. None of the remaining options are related to the symptoms present in the question and therefore are not appropriate interpretations.
A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk with the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur?
- A. Guilt
- B. Grief
- C. Anger
- D. Depression
Correct Answer: B
Rationale: The nurse should recognize that a mother will go through the grief process after giving birth to a child with a birth defect. After the grief process, the mother can begin to focus on bonding with the infant. The remaining options are incorrect because they are each only one component of the grief process.
The nurse was assigned to the mental health care area from another area in the facility. A client accuses the nurse of being a terrorist with poisonous pills when the nurse is preparing medications. Which response by the nurse is best?
- A. I am not a terrorist.
- B. Is it your feeling that I am trying to poison you?
- C. This is your medication, which you have to take now.
- D. I am a nurse from another unit in this hospital.
Correct Answer: B
Rationale: Reflecting the client’s feelings validates their emotions and opens therapeutic communication without confrontation, which is critical for a client with possible paranoia. Denying, insisting, or explaining may escalate distrust.
A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner?
- A. Ask a family member to stay with the client during the procedure.
- B. Give the client the call bell, and encourage its use if the client feels worse.
- C. Leave the client alone only to gather the required equipment and medications.
- D. Stay with the client, and ask another nurse to gather needed equipment and supplies.
Correct Answer: D
Rationale: The client with pulmonary edema is experiencing severe anxiety, which can exacerbate the condition and hinder treatment. Staying with the client provides emotional support and reassurance, addressing the psychosocial aspect of care, while delegating equipment gathering ensures efficient preparation for treatment. This holistic approach meets both the emotional and physical needs of the client. Option 1 may not be feasible or sufficient to address immediate anxiety. Option 2 does not provide active support, and option 3 leaves the client alone, which could increase anxiety.
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.