Nokea
Which action should the nurse implement when providing wound care instructions to a client who does not speak English?
- A. Ask an interpreter to provide wound care instructions.
- B. Speak directly to the client, with an interpreter translating.
- C. Request the accompanying family member to translate.
- D. Instruct a bilingual employee to read the instructions.
Correct Answer: B
Rationale: When providing wound care instructions to a client who does not speak English, the nurse should speak directly to the client with the assistance of an interpreter for accurate translation. The interpreter is trained to provide objective translations in the client's primary language, ensuring the client understands the instructions and can ask questions. Using family members for translation is discouraged as they may alter instructions or feel uncomfortable discussing certain topics. Instructing a bilingual employee to read the instructions is not ideal as they may lack the necessary training in accurate interpretation, which could lead to misunderstandings in crucial wound care instructions.
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A seriously ill female client tells the nurse, 'I am so tired and in so much pain! Please help me to die.' Which is the best response for the nurse to provide?
- A. Administer the prescribed maximum dose of pain medication.
- B. Talk with the client about her feelings related to her own death.
- C. Collaborate with the healthcare provider about initiating antidepressant therapy.
- D. Refer the client to the ethics committee of her local healthcare facility.
Correct Answer: B
Rationale: The nurse should first assess the client's feelings about her death and determine the extent to which this statement expresses her true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Option B is the correct response as it focuses on addressing the client's emotional needs and providing support. Option C is premature as initiating antidepressant therapy without a thorough assessment may not be appropriate. Option D is not the best course of action at this point; involving the ethics committee should be considered only after a comprehensive evaluation and discussion with the client.
A client is having difficulty applying for a job due to panic and anxiety. A nurse is helping by pretending to be the job supervisor while the client practices answering questions during an imaginary interview. This technique is an example of:
- A. Reinforcement
- B. Presenting reality
- C. Role playing
- D. Summarizing
Correct Answer: C
Rationale: Role-playing is the correct answer. It involves practicing appropriate behaviors during imaginary scenarios that simulate real-life situations. In this scenario, the nurse is helping the client prepare for a job interview by acting as the job supervisor. Role-playing allows the client to practice and develop strategies to cope with anxiety and panic during the actual interview. Reinforcement (Choice A) involves providing consequences to strengthen a behavior. Presenting reality (Choice B) involves helping the client differentiate between real and unreal experiences. Summarizing (Choice D) involves condensing information. In this context, role-playing is the most appropriate technique to address the client's anxiety and panic related to job interviews.
Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?
- A. Make the client comfortable and allow the client to sleep.
- B. Assess the client's neurologic status.
- C. Notify the surgeon about the comment.
- D. Ask the client's family to co-sign the operative permit.
Correct Answer: B
Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.
Which of the following is an advantage of working with psychiatric clients in a group setting?
- A. Clients assist each other through therapeutic interventions with the support of a nurse
- B. Clients can receive peer support and feedback in a safe and controlled environment
- C. Clients can share experiences and coping strategies while maintaining confidentiality
- D. Clients learn from others when their behaviors are inappropriate in a safe and trusting environment
Correct Answer: D
Rationale: Group therapy is a valuable approach in mental health treatment. Working with psychiatric clients in a group setting offers various benefits. Clients in a group setting can learn from others when their behaviors are inappropriate in a safe and trusting environment. This environment allows individuals to express thoughts and feelings without fear of judgment or criticism, fostering a supportive atmosphere. Through interactions with peers, clients can gain insight into their own behaviors and learn alternative ways of coping. Choice A is incorrect as the presence and support of a nurse are typically important in group therapy sessions. Choice B is incorrect as group settings provide structure and rules to ensure a safe space for clients to express themselves. Choice C is incorrect as maintaining confidentiality is crucial in group therapy to build trust and encourage open sharing.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?
- A. Clamp the catheter and recheck it in 60 minutes.
- B. Pull the catheter back 3 inches and redirect upward.
- C. Leave the catheter in place and reattempt with another catheter.
- D. Notify the healthcare provider of a possible obstruction.
Correct Answer: C
Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option D) as the catheter could be inserted easily.