Nokea
The parent of an infant client with tetralogy of Fallot (TOF) is pumping her breasts at the client's bedside. The unlicensed assistive personnel (UAP) says to the nurse, 'She should breast feed that baby instead of pumping all the time. What's wrong with her?' Which is the best response for the nurse to make?
- A. You sound upset about what you observed.
- B. Why don't you ask her why she is pumping?
- C. What do you understand about her baby's illness?
- D. It's not our business to judge the decisions of others.
Correct Answer: C
Rationale: Asking the UAP about their understanding of the baby’s condition encourages education and clarifies why pumping may be necessary (e.g., due to the infant’s cardiac condition). This promotes teamwork and understanding without judgment or confrontation.
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The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for communication should the nurse determine may be the best for the client?
- A. Use a picture or word board.
- B. Have the family interpret needs.
- C. Devise a system of hand signals.
- D. Use a pad of paper and a pencil.
Correct Answer: A
Rationale: The client with an endotracheal tube in place cannot speak, so the nurse devises an alternative communication system with the client. The use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. The family does not need to bear the burden of communicating the client's needs, and they may not understand the client either. The use of hand signals may not be a reliable method because it may not meet all needs, and it is subject to misinterpretation. A pad of paper and a pencil is an acceptable alternative, but it requires more client effort and time.
The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.)
- A. Keep the voice even throughout conversations.
- B. Explain the sounds in the environment.
- C. Decrease background noise before speaking.
- D. Stay in the client's field of vision.
- E. Identify self by name and staff position.
Correct Answer: A,B,C,D,E
Rationale: All options are appropriate: (A) Even voice tone ensures clarity; (B) Explaining sounds reduces confusion; (C) Reducing noise aids hearing; (D) Staying in the field of vision supports communication; (E) Identifying self orients the client. These interventions enhance safety and interaction.
A client diagnosed with acute kidney injury is having trouble remembering information and instructions as a result of altered laboratory values. Which actions should the nurse take when communicating with this client? Select all that apply.
- A. Give simple, clear directions.
- B. Include the family in discussions related to care.
- C. Explain treatments using understandable language.
- D. Explain the possibility of hemodialysis in simple terms.
- E. Give thorough and complete explanations of treatment options.
Correct Answer: A,B,C,D
Rationale: The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and altered laboratory values. Communications should be clear, simple, and understandable. The family is included whenever possible. Information about treatment should be explained using understandable language. Thorough and complete explanations may be confusing and will not be understandable for the client.
The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
- A. somatic delusion
- B. delusion of grandeur
- C. delusion of persecution
- D. delusion of control or influence
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.