Nokea
The parent of a child who was just diagnosed with hemophilia A is talking to the pediatric nurse. Which statement from the parent does the nurse respond to first?
- A. I feel so guilty-like it is all my fault.
- B. I do not know how we will afford this.
- C. It scares me to think my child will be bleeding all the time.
- D. We were looking forward to watching our child play sports.
Correct Answer: C
Rationale: The fear of constant bleeding indicates a misunderstanding of hemophilia and significant anxiety, which could impact caregiving. Addressing this concern first clarifies the condition and reduces fear, taking priority over guilt, financial worries, or lifestyle changes.
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A preschooler has just been diagnosed with impetigo. The child's mother tells the nurse, 'But my children take baths every day.' Which therapeutic response should the nurse make to the mother?
- A. You are concerned about how your child got impetigo?'
- B. There is no need to worry. We will not tell your day care provider why your child is absent.'
- C. Not only do you have to do a better job of keeping your children clean, you must also wash your hands more frequently.'
- D. You should have seen the doctor before the wound became infected, and then you would not have had to worry about the child having impetigo.'
Correct Answer: A
Rationale: By paraphrasing what the parent tells the nurse, the nurse is addressing the parent's thoughts. Option 1 demonstrates the therapeutic technique of paraphrasing. The remaining options are blocks to communication because they make the parent feel guilty for the child's illness.
An English-speaking Hispanic client has a newly applied long leg cast to stabilize a right proximal fractured tibia. During rounds at night, the nurse finds the client restless, withdrawn, and unusually quiet. Which nursing statement would be most appropriate?
- A. Are you uncomfortable?
- B. Tell me what you are feeling.
- C. You'll feel better in the morning.
- D. I'll get your pain medication right away.
Correct Answer: B
Rationale: Option 2 is open-ended and makes no assumptions about the client's psychological or emotional state. Option 1 is incorrect because males in traditional standard Hispanic cultures practice 'machismo' in which stoicism is valued, so this client may deny any pain when asked. False reassurance is never therapeutic, which makes option 3 incorrect. Option 4 is incorrect because an assessment is necessary before administering medication for pain.
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a diagnosis of major depressive disorder. Which assessment findings should the nurse identify as expected short-term side effects of ECT that do not require notifying the primary health care provider?
- A. Confusion
- B. Memory loss
- C. Hypertension
- D. Disorientation
- E. Heart palpitations
Correct Answer: A,B,D
Rationale: The major expected side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure or presence of heart palpitations would not be anticipated side effects and would be causes for concern. If hypertension or presence of heart palpitations occurred after ECT, the primary health care provider should be notified.
The nurse is assessing a client who is a polysubstance abuser, with fentanyl being one of the drugs most frequently used. Which physiological symptoms are suggestive of fentanyl intoxication? Select all that apply.
- A. diarrhea
- B. nausea
- C. urge to urinate
- D. anxiety
Correct Answer: B
Rationale: Nausea is a common symptom of fentanyl intoxication. Diarrhea, urge to urinate, and anxiety are not typical physiological signs.
A client was just told by the primary care primary health care provider that he will have an exercise stress test to evaluate his status after recent episodes of severe chest pain. As the nurse enters the examining room, the client states, 'Maybe I shouldn't bother going. I wonder if I should just take more medication instead.' Which therapeutic response should the nurse make to the client?
- A. Can you tell me more about how you're feeling?'
- B. Don't you really want to control your heart disease?'
- C. Most people tolerate the procedure well without any complications.'
- D. Don't worry. Emergency equipment is available if it should be needed.'
Correct Answer: A
Rationale: Anxiety and fear are often present before stress testing. The nurse should explore a client's feelings if concerns are expressed. Option 1 is open-ended and is the only choice that is phrased to engender trust and the sharing of concerns by the client. Eliminate options that are inappropriate statements and limit communication.