Nokea
The nurse provides care for an older adult client who is disoriented to person, place, and time. The client has an incontinence episode. Which statement by the nurse is most appropriate?
- A. Let's see about placing an indwelling catheter.
- B. Why didn't you call us for assistance?
- C. Here are some dry clothes for you to wear.
- D. Let's clean up and put on some dry clothes.
Correct Answer: D
Rationale: Offering to clean up and provide dry clothes is compassionate, maintains dignity, and addresses the immediate need without judgment. Catheters are invasive, blaming the client is inappropriate, and simply offering clothes does not address hygiene.
You may also like to solve these questions
A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, 'I know I need it, but I'm not sure this surgery is a great idea.' Which nursing response should best help the nurse assess the client's preoperative concerns?
- A. How does your family feel about the surgery?
- B. Has anyone taught you about the procedure yet?
- C. You sound extremely worried. Has anyone told you that the technology is really quite safe?
- D. You sound uncertain about the procedure. Can you tell me more about what has you concerned?
Correct Answer: D
Rationale: Anxiety is common in the client with the need for pacemaker insertion. This can be related to a fear of life-threatening dysrhythmias or of the surgical procedure. Option 4 is the correct choice because it is open-ended and uses clarification as a communication technique to explore the client's concerns. Option 1 is not indicated because it asks about the family and deflects attention away from the client's concerns. Options 2 and 3 are closed-ended and are not exploratory.
A postpartum client with a diagnosis of gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, 'Do I have to worry about this diabetes anymore?' Which is the most appropriate response by the nurse?
- A. Your blood glucose level is within normal limits now, so you will be all right.'
- B. You will have to worry about the diabetes only if you become pregnant again.'
- C. You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus.'
- D. When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your life.'
Correct Answer: C
Rationale: The client is at risk for developing gestational diabetes with each pregnancy. The client also has an increased risk for developing diabetes mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing diabetes mellitus; however, with proper care, it may not develop.
During the admission assessment of a client with a history of alcohol abuse for diagnosis of ruptured esophageal varices, the client says, 'I deserve this. I brought it on myself.' Which response is most therapeutic for the nurse to make to the client?
- A. Would you like to talk to the chaplain?
- B. Is there some reason you feel you deserve this?
- C. Not all esophageal varices are caused by alcohol.
- D. That is something to think about when you leave the hospital.
Correct Answer: B
Rationale: Ruptured esophageal varices are often a complication of cirrhosis of the liver, and the most common type of cirrhosis is caused by chronic alcohol abuse. It is important to obtain an accurate history regarding the client's alcohol intake. If the client is ashamed or embarrassed, he or she may not respond accurately. Option 2 is open-ended and allows the client to discuss his or her feelings about drinking. Option 1 blocks the nurse-client communication process. Options 3 and 4 are somewhat judgmental.
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
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.