Nokea
Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?
- A. I'm so angry that this happened to me.
- B. I really don't want to live my life like this.
- C. I'm definitely not looking forward to going home.
- D. I don't know if I can make all these major adjustments to my life.
Correct Answer: B
Rationale: It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness.
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A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, 'My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?' Which therapeutic response should the nurse make to the client's daughter?
- A. Tell me what you think you did wrong.'
- B. Maybe we can keep your father in the hospital for a while longer to give you a rest.'
- C. You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care.'
- D. An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed.'
Correct Answer: D
Rationale: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.
The nurse conducts a grief support group at the community mental health center. Which client will the nurse identify as needing additional assistance before participating in this group?
- A. Older adult male whose estranged spouse, living in another state, died from heart disease 3 months ago.
- B. Older adult female whose spouse died 3 years ago in a car accident.
- C. Middle-aged female who started drinking after the sudden death of the spouse 6 months ago.
- D. Young male with two children whose spouse died 1 year ago due to breast cancer.
Correct Answer: C
Rationale: The middle-aged female who began drinking after her spouse’s death indicates unhealthy coping and potential substance abuse, requiring individual intervention before group participation. Other clients show grief but no immediate maladaptive behaviors.
A client with a diagnosis of depression states to the nurse, 'I should have died. I've always been a failure.' Which therapeutic response should the nurse make to the client?
- A. You don't see anything positive?
- B. You still have a great deal to live for.
- C. Feeling like a failure is part of your illness.
- D. You've been feeling like a failure for some time now?
Correct Answer: D
Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate the exploration of the client's expressed feelings.
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, 'Became angry and physically abusive.' Which action does the nurse take first?
- A. Encourage the client to verbalize feelings.
- B. Assess the client for physical trauma.
- C. Provide a list of shelters appropriate for the situation.
- D. Assist the client to identify a support system.
Correct Answer: B
Rationale: Assessing for physical trauma is the priority to identify injuries requiring immediate medical attention, ensuring the client's safety. Verbalizing feelings, providing shelter lists, and identifying support systems are important but secondary to physical assessment.
When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic?
- A. Well, I can see you never got to the stop smoking clinic.
- B. Now that your secret is out, may we decide what you are going to do?
- C. Did you explore the stop smoking program at the senior citizens center?
- D. I wonder if you realize that by smoking you are slowly killing yourself.
Correct Answer: C
Rationale: Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client. Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In option 4, the nurse preaches and is judgmental.