Nokea
The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?
- A. Elevating the affected leg is indicated.'
- B. Keeping the affected leg flat encourages healing.'
- C. Engaging in activity as tolerated should be encouraged.'
- D. Maintaining bathroom privileges is the most important action.'
Correct Answer: A
Rationale: The nurse plans to elevate the affected extremity because this facilitates venous return by using gravity to improve blood return to the heart, decreases venous pressure, and helps relieve edema and pain. Option 2 does not facilitate venous return and thus is not indicated for a client with thrombophlebitis. Options 3 and 4 are unsuitable activities for a client on bed rest.
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The nursing student is listening to a lecture on correcting errors in a written narrative on a medical record. Which statement by the nursing student indicates that the teaching has been effective?
- A. The correct procedure is to document the correction as a late entry.'
- B. The correct procedure is to draw a line through the error to identify it.'
- C. The correct procedure is to remove the error in a manner approved by the facility.'
- D. The correct procedure is to cover the error completely using a permanent marker.'
Correct Answer: B
Rationale: If the nurse makes a narrative documentation error in the client's record, the agency's policy should be followed to correct the error. Agency policy usually includes drawing one line through the error, initialing and dating the line, and then providing the correct information. The nurse uses a late entry to document additional information that was not documented at the time that it occurred. The nurse avoids attempting to remove the error by any means because these actions raise the suspicion of wrongdoing.
A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears?
- A. Open-ended questions and silence
- B. Offering personal opinions about the need to eat
- C. Verbalizing reasons why the client may choose not to eat
- D. Focusing on self-disclosure of the nurse's own food preferences
Correct Answer: A
Rationale: Open-ended questions and silence are strategies that are used to encourage clients to discuss their feelings in a descriptive manner. Options 2 and 3 are not helpful to the client because they do not encourage the expression of personal feelings. Option 4 is not a client-centered intervention.
The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?
- A. Do you have concerns about managing your condition?'
- B. Do you think you might need to go to the nursing home?'
- C. If you take the correct medications, I doubt this will happen again.'
- D. Don't worry. I'm sure your family will provide all the help you need.'
Correct Answer: A
Rationale: The nurse should provide time and listen to the client's concerns while attempting to clarify the client's feelings as in the correct option. Option 2 is not an appropriate nursing response because it is making suggestions regarding care options without appropriately identifying the client's true concerns. Options 3 and 4 provide inappropriate false hope and disregard the client's concerns.
A client diagnosed with delirium anxiously states, 'Look at the spiders on the wall.' Which response by the nurse addresses the client's concerns therapeutically?
- A. Would you like me to kill the spiders for you?'
- B. While there may be spiders on the wall, they are not going to hurt you.'
- C. I know that you are frightened, but I do not see any spiders on the wall.'
- D. You are having a hallucination; I'm sure there are no spiders in this room.'
Correct Answer: C
Rationale: When hallucinations are present, the nurse should reinforce reality with the client while acknowledging the client's feelings as the correct option does. Eliminate options 1, 2, and 4 because they do not reinforce reality but rather support the legitimacy of the hallucination or that reinforces reality but does not address the client's feelings.
The partner of a client who has an esophageal tube introduced for a second time tells the nurse, 'I thought having this tube down the nose the first time would convince anyone to quit drinking.' Which response to the statement should the nurse make?
- A. I think you are a good person to stay with her.'
- B. Alcoholism is a disease that affects the whole family.'
- C. Have you discussed this subject at the Al-Anon meetings?'
- D. You sound frustrated dealing with such a drinking problem.'
Correct Answer: D
Rationale: In option 4, the nurse uses the therapeutic communication techniques of clarifying and focusing to assist the client's partner with expressing feelings about the client's chronic illness. Showing approval, stereotyping, and changing the subject are nontherapeutic techniques that block communication.