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When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic?
- A. Well, I can see you never got to the stop smoking clinic.
- B. Now that your secret is out, may we decide what you are going to do?
- C. Did you explore the stop smoking program at the senior citizens center?
- D. I wonder if you realize that by smoking you are slowly killing yourself.
Correct Answer: C
Rationale: Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client. Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In option 4, the nurse preaches and is judgmental.
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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 is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
A client with the diagnosis of hyperparathyroidism states to the nurse, 'I can't stay on this diet. It is too difficult for me.' Which therapeutic response by the nurse is best when intervening in this situation?
- A. Why do you think you find this diet plan difficult to adhere to?
- B. It really isn't difficult to stick to this diet. Just avoid milk products.
- C. You are having a difficult time staying on this plan. Let's discuss this.
- D. It is very important that you stay on this diet to avoid forming renal calculi.
Correct Answer: C
Rationale: By paraphrasing the client's statement, the nurse can encourage the client to verbalize emotions. The nurse also sends feedback to the client that the message was understood. An open-ended statement or question such as this prompts a thorough response from the client. Option 1 requests information that the client may not be able to express. Option 2 devalues the client's feelings. Option 4 gives advice, which blocks communication.
A client in the long-term care facility is confused and repeatedly asks the nurse for help finding the assigned room. Which response by the nurse is appropriate?
- A. Here is a map of the facility, including the room numbers.
- B. I think you can find your room if you just concentrate.
- C. Your room is on the first floor by the elevator doors.
- D. You didn't have any trouble finding your room yesterday.
Correct Answer: C
Rationale: Providing a clear, specific direction (room location by the elevator) helps orient the confused client without frustration. Maps are too complex, urging concentration is unhelpful, and referencing past ability may cause distress.
A client diagnosed with an obsessive-compulsive disorder spends many hours during the day and night washing hands. The nurse should initially allow the client to continue this behavior because it has what therapeutic effect for the client?
- A. Relieves the client's anxiety
- B. Decreases the chance of infection
- C. Gives the client a feeling of self-control
- D. Increases the client's sense of self-esteem
Correct Answer: A
Rationale: The compulsive act provides immediate relief from anxiety and is used to cope with stress, conflict, or pain. Options 2 and 3 are also incorrect interpretations of the client's need to perform this behavior. Although the client may feel the need to increase self-esteem, that is not the primary goal of this behavior.