Nokea
Which of the following indicates that a client is beginning to develop a trusting relationship with the nurse?
- A. The client describes delusions to the nurse.
- B. The client can describe his/her feelings to the nurse.
- C. The nurse feels more comfortable with the client.
- D. The client reports feeling less anxious.
Correct Answer: B
Rationale: Sharing feelings indicates trust, a key to therapeutic relationships. Options A, C, and D are less direct indicators.
You may also like to solve these questions
A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding.
- A. Which statement by a woman at 38-weeks gestation with vaginal bleeding suggests placenta previa?
- B. I feel fine, but the bleeding scares me.'
- C. I’ve been more nauseated during the past few weeks.'
- D. The bleeding started after I carried four bags of groceries.'
- E. I’ve been having severe abdominal cramps.'
Correct Answer: A
Rationale: Placenta previa is characterized by painless vaginal bleeding, as the placenta covers the cervical os. The statement ‘I feel fine, but the bleeding scares me’ indicates bleeding without pain, consistent with placenta previa. Nausea, activity-related bleeding, or cramps suggest other causes like abruptio placentae.
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: Hypotension (90/60 mmHg) is a serious carvedilol side effect, risking perfusion in heart failure. Options B, C, and D are normal.
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. disclose the information before the child knows or suspects.
- B. be comfortable with your sexual preference first.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. explain how your relationship with the child changes because of the discussion.
Correct Answer: D
Rationale: Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
- A. 1-2 inches
- B. 3-4 inches
- C. 5-6 inches
- D. 7-9 inches
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.