Nokea
Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?
- A. Asking to speak to someone
- B. Asking to be alone
- C. Listening to music
- D. All of the above
Correct Answer: D
Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.
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The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety?
- A. My son came to visit me yesterday.
- B. At least I can speak and answer questions.
- C. I have a problem turning my neck to the side.
- D. Look at me, I can no longer be the head of my family.
Correct Answer: D
Rationale: With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.
When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?
- A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
- B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
- C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
- D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.
Correct Answer: B
Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
- A. Encourage the client to increase ambulation in the room.
- B. Offer the client a high-carbohydrate snack for energy.
- C. Force fluids to thin the client's pulmonary secretions.
- D. Determine if pain is causing the client's tachypnea.
Correct Answer: D
Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate). Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload. Therefore, determining the role of pain in tachypnea is crucial for appropriate management.
The nurse is caring for a client who is a victim of domestic violence. Which of the following would the nurse expect to find in the client's social history? Select all that apply.
- A. The client is under 30 years old.
- B. The client is active in a local charity.
- C. The client has a history of child abuse.
- D. The client has been in past abusive relationships.
- E. The client is employed as a college professor.
Correct Answer: C,D
Rationale: History of child abuse and past abusive relationships are risk factors for domestic violence. Age, charity involvement, or profession are not specific risk factors.
A mother states to the nurse, 'I am afraid that my child might have another febrile seizure.' Which therapeutic statement is best for the nurse to make to the mother?
- A. Tell me what frightens you the most about seizures.
- B. Tylenol can prevent another seizure from occurring.
- C. Most children will never experience a second seizure.
- D. Why worry about something that you cannot control?
Correct Answer: A
Rationale: Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings. Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear.