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.
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The nurse is admitting a client who is to undergo ureterolithotomy. Which should the nurse assess in order to determine if the client is ready for surgery?
- A. The need for a visit from a support group
- B. The knowledge of postoperative activities
- C. An understanding of the surgical procedure
- D. Expected outcomes of the surgical procedure
- E. Feelings or anxieties about the surgical procedure
Correct Answer: B,C,D,E
Rationale: Ureterolithotomy is the removal of a calculus from the ureter using either a flank or abdominal incision. The client should have an understanding of the same items as are required for any surgery, including knowledge of the procedures, the expected outcome, the postoperative routines, and any expected discomfort. The client should also be assessed for any concerns or anxieties before surgery. Because no urinary diversion is created during this procedure, the client has no need for a visit from a member of a support group.
A client having premature ventricular contractions states to the nurse, 'I'm so afraid that something bad will happen.' Which action by the nurse provides the most immediate help to the client?
- A. Telephoning the client's family
- B. Using a television to distract the client
- C. Having a staff member stay with the client
- D. Giving reassurance that nothing will happen to the client
Correct Answer: C
Rationale: When a client experiences fear, the nurse can provide a calm, safe environment by offering appropriate reassurance, using therapeutic touch, and having someone remain with the client as much as possible. Options 1 and 2 do not address the client's fear, and option 4 provides false reassurance.
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.
A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, 'I'm not sure I can take any more of this treatment.' Which therapeutic response should the nurse make to the client?
- A. Let's just put the tube down, so that you can get well.'
- B. If you don't have this tube put down, you will just continue to vomit.'
- C. You are feeling tired and frustrated with your recovery from surgery?'
- D. It is your right to refuse any treatment. I'll notify the primary health care provider.'
Correct Answer: C
Rationale: In option 3, the nurse uses empathy. Empathy, comprehending, and sharing a client's frame of reference are important components of the nurse-client relationship. This assists clients with expressing and exploring feelings, which can lead to problem-solving. The other options are examples of barriers to effective communication, including option 1, which is stereotyping; option 2, which is defensiveness; and option 4, which is showing disapproval.
A pregnant client comes into the prenatal clinic accompanied by her spouse. The spouse states they were in a car accident and his wife's abdomen hit the steering wheel. The nurse observes the client wringing her hands and not making eye contact. The client's record shows two recently missed prenatal appointments. Which action does the nurse take?
- A. Make eye contact with the client and ask about the accident.
- B. Accompany the client into the restroom to obtain a urine sample.
- C. Ask the husband if the wife had been drinking alcohol.
- D. Escort the couple to an examining room to await the health care provider.
Correct Answer: D
Rationale: Escorting the couple to an examining room prioritizes a safe, private assessment of the client’s condition post-accident, especially given signs of possible abuse (missed appointments, anxiety). Direct questioning or accusations may escalate tension, and a urine sample is not the priority.