Nokea
When responding to the call bell, the nurse finds the client lying on the floor beside the bed. After a thorough assessment and appropriate care, the nurse completes an incident report. How should the incident be described in the report?
- A. The client fell out of bed and was found on the floor.
- B. The client fell while climbing over the bed's side rails.
- C. The client was found lying on the floor beside the bed.
- D. The client was restless and fell while getting out of bed.
Correct Answer: C
Rationale: The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only option that describes the facts as observed by the nurse. All the remaining options are interpretations of the situation and are not factual data as observed by the nurse.
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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.
A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What question best demonstrates the nurse's ability to use therapeutic communication techniques to effectively assess the teenager's feelings about using a cane?
- A. How do you feel about needing a cane to walk?'
- B. Do you have questions about ambulating with a cane?'
- C. Are you worried about what your friends will think about your cane?'
- D. What types of problems do you think you'll have ambulating with a cane?'
Correct Answer: A
Rationale: The nurse effectively uses therapeutic communication techniques when posing an open-ended question to elicit assessment data about how the teenager feels about using a cane. The remaining options are closed-ended questions. Option 3 makes assumptions about how the teenager feels, and options 2 and 4 focus on the physical aspects of using the cane.
The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse-client relationship. Which intervention is representative of this phase of the relationship?
- A. The nurse and client determine the contract for time.
- B. The client is encouraged to make use of all services depending on need.
- C. The client begins to identify with the nurse, and trust and rapport are maintained.
- D. The nurse focuses on facilitating the therapeutic expression of the client's feelings.
Correct Answer: A
Rationale: In the orientation (introductory phase) of the therapeutic nurse-client relationship, the client and nurse meet and determine the contract for time, such as how often to meet, the length of the meetings, and when termination is anticipated to occur. Utilizing services, identification with the nurse, and expression of feelings are appropriate for the working phase of the therapeutic nurse-client relationship.
A client diagnosed with angina pectoris appears to be very anxious and states, 'So, I had a heart attack, right?' Which response should the nurse make to the client?
- A. No. That is not why you are hospitalized.'
- B. No, but there could be some minimal damage to your heart.'
- C. No, not this time and we will do our best to prevent a future heart attack.'
- D. No, but it's necessary to monitor you and control or eliminate your pain.'
Correct Answer: D
Rationale: Angina pectoris occurs as a result of an inadequate blood supply to the myocardium causing pain; managing the condition will help address the client's pain. The nurse will want to correct the client's misconception regarding a heart attack while addressing the client's concerns. Option 1 does not address the client's concerns. Option 2 is not correct because angina involves interrupted blood supply but does not result in cardiac tissue damage. Neither the nurse nor the primary health care provider can guarantee that a heart attack will not occur as option 3 seems to indicate.
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.