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Which action should the nurse take first during the initial phase of implementation?
- A. Determine patient outcomes and goals.
- B. Prioritize patient’s nursing diagnoses.
- C. Evaluate interventions.
- D. Reassess the patient.
Correct Answer: D
Rationale: The correct answer is D: Reassess the patient. During the initial phase of implementation, the nurse should first reassess the patient to gather current data and evaluate the effectiveness of previous interventions. This step ensures that the nurse has updated information to make informed decisions about the patient's care. A: Determining patient outcomes and goals should come after reassessment. B: Prioritizing nursing diagnoses is important but should be based on current assessment data. C: Evaluating interventions should be done after implementing them and giving them time to take effect.
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A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends’s behavior shows that they aren’t true friends
Correct Answer: C
Rationale: The correct answer is C: Listen and show interest as the client expresses feelings. It is essential for the nurse to actively listen and show empathy towards the client's emotional distress. This approach demonstrates compassion, understanding, and support for the client during a vulnerable moment, which is crucial for the therapeutic relationship. By actively listening, the nurse can validate the client's emotions and provide a safe space for them to express their feelings. This can help the client feel heard and supported, leading to improved emotional well-being.
Choices A, B, and D are incorrect:
A: Continuing with the bath and telling the client not to worry dismisses the client's emotions and fails to address their underlying feelings of loneliness and isolation.
B: Asking for a psychiatric consultation may not be necessary at this point, as the client's emotional distress can be effectively managed through therapeutic communication.
D: Stating that the friends' behavior shows they aren't true friends is judgmental and unhelpful, as it does not address
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The correct answer is B because optimum sleep helps regulate breathing patterns during an EEG. Waking the client at midnight allows them to have a full night's rest, ensuring they are well-rested and their breathing is stable for accurate EEG results. Choice A is incorrect as excess sleep does not affect nervousness. Choice C is incorrect as waking the client does not help them fall asleep naturally during the EEG. Choice D is incorrect as headache prevention is not directly related to waking the client at midnight.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being.
Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.
Which of the following outcomes is correctly written?
- A. Abdominal incision will show no signs of infection.
- B. On discharge, client will be free of infection.
- C. On discharge, client will be able to list five symptoms of infection.
- D. During home care, nurse will not observe symptoms of infection.
Correct Answer: C
Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
- A. Cool, clammy skin
- B. Increased urine osmolarity
- C. Distended neck veins
- D. serum sodium level
Correct Answer: B
Rationale: The correct answer is B: Increased urine osmolarity. In hyperglycemia, the body tries to eliminate excess glucose through increased urine output, causing a concentrated urine with high osmolarity. This indicates fluid deficit. Cool, clammy skin (A) may suggest poor perfusion but not fluid volume deficit. Distended neck veins (C) are more indicative of fluid overload. Serum sodium level (D) may be elevated in fluid deficit but does not directly assess volume status like urine osmolarity does.