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The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)
- A. Remain with the client.
- B. Contact the police to interview the client.
- C. Administer prescribed lorazepam 1 mg orally.
- D. Encourage client to describe the incident.
- E. Provide privacy for the client.
- F. Write down important information.
Correct Answer: A,C,E,F
Rationale: Appropriate interventions include: (A) Remaining with the client for support; (C) Administering lorazepam to reduce anxiety; (E) Providing privacy to create a safe space; (F) Writing down information to aid communication. Police interviews (B) or describing the incident (D) may increase distress and are not immediate priorities.
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A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The physical demands of the client's lifestyle
- B. The ability to comply with anticoagulant therapy for life
- C. The ability to participate in a cardiac rehabilitation program
- D. The likelihood of the client experiencing body image problems
Correct Answer: B
Rationale: Mechanical valves carry the associated risk of thromboemboli, which require long-term anticoagulation with warfarin sodium. No data in the question indicate that physical demands exist in the client's lifestyle. Not all clients who undergo cardiac surgery require cardiac rehabilitation. Body image problems are important but not critical.
Which nursing intervention helps foster the development of a trusting parent-child relationship?
- A. Placing the infant in a crib with a mobile or soft toy
- B. Discouraging eye contact when the infant is irritable
- C. Putting objects several inches in front of the infant for viewing
- D. Encouraging face-to-face contact between the parents and infant
Correct Answer: D
Rationale: Encouraging face-to-face contact between parents and infants is crucial in fostering a trusting parent-child relationship. Eye-to-eye contact promotes interaction and bonding, helping the infant develop trust in their caregivers. Placing the infant in a crib with a mobile or soft toy may provide stimulation but does not directly contribute to the emotional bonding necessary for trust. Discouraging eye contact when the infant is irritable can hinder communication and connection. Putting objects in front of the infant for viewing is beneficial for visual stimulation but does not actively promote the emotional attachment and trust that face-to-face contact does.
The nurse is performing a neurological assessment on a client with a diagnosis of dementia and assessing the function of the frontal lobe of the brain. Which should the nurse assess to yield the best information about this area of functioning?
- A. Eye movements
- B. Feelings or emotions
- C. Level of consciousness
- D. Insight, judgment, and planning
Correct Answer: D
Rationale: Insight, judgment, and planning are part of the function of the frontal lobe. Eye movements are under the control of cranial nerves III, IV, and VI. Feelings and emotions are part of the role of the limbic system. The level of consciousness is controlled by the reticular activating system.
A client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. Which action would the nurse take?
- A. Evaluate her willingness to pursue adoption.
- B. Encourage her to focus on her own recovery.
- C. Emphasize that she does have two children already.
- D. Ensure that other treatment options for her are explored.
Correct Answer: D
Rationale: In this scenario, the nurse should ensure that other treatment options for the client are explored. While a hysterectomy may be necessary for cervical cancer, conservative management options like cervical conization and laser treatment may allow for future pregnancies. It is crucial for the nurse to inform the client of all available treatment choices. Evaluating the client's willingness to pursue adoption is not directly addressing the client's concerns about fertility. Encouraging the client to focus on her own recovery and emphasizing that she already has two children dismiss the client's distress over not being able to have a third child, which is important to acknowledge in a sensitive manner.
A client is having a panic attack. Which nursing intervention has priority for this client?
- A. have the client recount a positive childhood memory
- B. provide the client with a glass of water
- C. tell the client to take deep breaths
- D. ask the client to identify the source of his anxiety
Correct Answer: C
Rationale: Deep breathing helps reduce hyperventilation and physiological symptoms during a panic attack, making it the priority intervention.