Nokea
Which of these is a form of therapeutic communication?
- A. Probing for more information from the client
- B. Sublimation to determine hidden messages
- C. Providing privacy so the client is comfortable
- D. Silence to allow contemplation and thought
Correct Answer: D
Rationale: Silence is a therapeutic communication technique that allows the client time to process thoughts and emotions, fostering reflection.
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The nurse is caring for a young adult client diagnosed with sarcoidosis. The client is angry and tells the nurse that there is no point in learning disease management because there is no possibility of ever being cured. Based on the client's statement, the nurse determines that the client is experiencing which potential problem?
- A. Apprehension
- B. Powerlessness
- C. Intellectualization
- D. Ineffective thought process
Correct Answer: B
Rationale: The client with powerlessness expresses feelings of having no control over a situation or outcome. Apprehension is fearful or uneasy anticipation of something. Intellectualization is excessive reasoning to avoid feeling. Ineffective thought process involves interruption in normal thought.
A client has been taking furosemide (Lasix) for 2 days. The nurse should assess the client for:
- A. An elevated blood urea nitrogen (BUN) level.
- B. An elevated potassium level.
- C. A decreased potassium level.
- D. An elevated sodium level.
Correct Answer: C
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, requiring assessment for decreased potassium levels.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Sepsis.
- B. Hypovolemia.
- C. Hyperkalemia.
- D. Respiratory distress.
- E. Hypoglycemia.
Correct Answer: A, B, C, D
Rationale: Burns can cause sepsis (infection), hypovolemia (fluid loss), hyperkalemia (tissue damage), and respiratory distress (inhalation injury).
The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety?
- A. Oxygen used 30 feet from a gas stove
- B. Oxygen tank stored in the tank holder
- C. No smoking' sign posted at the front door
- D. Oxygen concentrator propped against a wall
Correct Answer: D
Rationale: The oxygen concentrator should be free and clear of walls or other enclosed spaces to allow adequate air circulation around the unit; otherwise, the unit can overheat and increase the risk of fire. Clients should avoid using oxygen within 10 feet of open flames because oxygen fuels a fire. Oxygen tanks are secured in a holder to stabilize and protect the tank, and a 'no smoking' sign should be in view to alert visitors about the risk.
Buspirone hydrochloride is prescribed for a client diagnosed with an anxiety disorder. The nurse providing instructions should inform the client about which characteristic of this medication?
- A. There is risk of addiction.
- B. Dizziness and nausea may occur.
- C. Tolerance can occur with the medication.
- D. The medication can produce a sedating effect.
Correct Answer: B
Rationale: Buspirone hydrochloride is used in the management of anxiety disorders. The medication has a more favorable side effect profile than do the benzodiazepines. Dizziness, nausea, headaches, lightheadedness, and paradoxical central nervous system excitement, which generally are not major problems, are side effects of the medication. The advantages of this medication are that it is not addicting, tolerance does not develop, and it is not sedating.