Nokea
Which response would the nurse provide to a client in labor at 32 weeks' gestation who tells the nurse that she and her husband are very concerned because the baby will be born 2 months early?
- A. You should be concerned. I feel for you.''
- B. If you're concerned, let's talk about it.''
- C. Try not to worry about it; just concentrate on your labor.''
- D. Don't worry; the care of preterm babies has greatly improved.''
Correct Answer: B
Rationale: The correct answer is B: ''If you're concerned, let's talk about it.'' Offering to talk with the client encourages her to verbalize concerns, serving as an outlet for tension. The nurse's first step should be to listen to the client's concerns and emotions before providing more specific information. Choice A is incorrect as telling the client she should be concerned reinforces fears and conveys sympathy rather than empathy. Choice C is incorrect because telling the client not to worry and just concentrate on labor denies the client's feelings and cuts off communication. Choice D is incorrect as telling the client not to worry because care has improved denies the client's feelings and provides false reassurance.
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For which condition would electroconvulsive therapy (ECT) be used?
- A. Severe clinical depression
- B. Substance abuse disorders
- C. Antisocial personality disorder
- D. Psychosis occurring in schizophrenia
Correct Answer: A
Rationale: Electroconvulsive therapy (ECT) is indicated for severe clinical depression, especially in cases where clients do not respond well to psychotropic medications or require immediate intervention due to the severity of their depression. ECT is not typically used as a primary treatment for substance abuse disorders, antisocial personality disorder, or psychosis occurring in schizophrenia. While ECT is an effective intervention for severe depression, it is important to consider individual client needs and response to other treatment options before resorting to ECT.
The client is a 35-year-old multiparous individual scheduled for a tubal ligation. The nurse assesses the client's emotional response to the planned procedure. Which factor in the client's history will contribute to the healthy resolution of any emotional problem associated with sterilization?
- A. Belief that the surgery will relieve her monthly dysmenorrhea
- B. Knowledge that her partner does not want to have any more children
- C. Feeling that her family is complete and she now has the children she planned for
- D. Recovery from her previous complicated birth and a desire to avoid another birth
Correct Answer: C
Rationale: The correct answer is feeling that her family is complete and she now has the children she planned for. Many couples in their 30s who feel that their families are complete choose sterilization as their method of contraception. Sterilization by means of tubal ligation should not be expected to have an effect on dysmenorrhea. The decision to undergo sterilization should be the individual's own choice and should not be influenced by others, including partners. Decisions regarding sterilization should ideally be made when the individual is not under stress, such as after recovery from a previous complicated birth. Therefore, the key factor contributing to a healthy resolution of emotional issues related to sterilization is the feeling of family completeness and achieving the planned number of children.
Which intervention should the nurse use for a client who hallucinates, yells, and curses throughout the day?
- A. Ignore the client's behavior if the client is not harming anyone.
- B. Isolate the client until the behavior decreases or stops.
- C. Explain how the behavior affects other people on the unit.
- D. Seek to understand what the behavior means to the client.
Correct Answer: D
Rationale: When a client experiences hallucinations, yells, and curses, it is essential to seek to understand the underlying meaning of their behavior. All behavior has significance, and understanding the client's perspective can guide appropriate interventions. Ignoring the behavior may exacerbate the situation and isolating the client could lead to increased anxiety and further acting out. Explaining the impact on others is not helpful in this scenario as the client is not intentionally hallucinating; yelling and cursing are responses to the hallucinations.
What is the nurse's priority action when a client receiving a unit of packed red blood cells experiences tingling in the fingers and headache?
- A. Call the health care provider (HCP).
- B. Stop the transfusion.
- C. Slow the infusion rate.
- D. Assess the intravenous (IV) site for infiltration.
Correct Answer: B
Rationale: When a client receiving a packed red blood cell transfusion experiences tingling in the fingers and headache, these symptoms may indicate an adverse reaction to the transfusion. The nurse's priority action is to immediately stop the transfusion and initiate a normal saline infusion at a keep vein open (KVO) rate. This helps maintain the client's vein patency while addressing the adverse reactions. After stopping the transfusion and initiating the saline infusion, the nurse should assess the client, including vital signs evaluation. Subsequently, the healthcare provider should be notified. Calling the healthcare provider is important, but it should be done after the immediate action of stopping the transfusion. Slowing the infusion rate is not appropriate during a suspected transfusion reaction as it can exacerbate the adverse effects. Assessing the IV site for infiltration is a routine nursing intervention and is not the priority when managing a potential adverse reaction to a blood transfusion.
What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?
- A. Ask where the client obtained the alcohol.
- B. Locate the alcoholic substance.
- C. Convey empathy and support to the client.
- D. Document the client's drinking behavior.
Correct Answer: B
Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.