Nokea
While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit the most useful response for determining the client's degree of adjustment to the new diagnosis?
- A. Is there anyone to help with housework and shopping?'
- B. How do you feel about making changes to your lifestyle?'
- C. Do you understand the schedule for your new medications?'
- D. Did you make a follow-up appointment with your provider?'
Correct Answer: B
Rationale: Exploring feelings assists the nurse with determining the individualized plan of care for the client who is adjusting to a new diagnosis. The correct option is the best question to ask the client because it is likely to elicit the most revealing information about the client's feelings about CAD and the requisite lifestyle changes that can help maintain health and wellness. The remaining choices are aspects of post-hospital care, but they are unlikely to uncover as much information about the client's adjustment to CAD because they are closed-ended questions.
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The partner of a client who has an esophageal tube introduced for a second time tells the nurse, 'I thought having this tube down the nose the first time would convince anyone to quit drinking.' Which response to the statement should the nurse make?
- A. I think you are a good person to stay with her.'
- B. Alcoholism is a disease that affects the whole family.'
- C. Have you discussed this subject at the Al-Anon meetings?'
- D. You sound frustrated dealing with such a drinking problem.'
Correct Answer: D
Rationale: In option 4, the nurse uses the therapeutic communication techniques of clarifying and focusing to assist the client's partner with expressing feelings about the client's chronic illness. Showing approval, stereotyping, and changing the subject are nontherapeutic techniques that block communication.
The nurse assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document?
- A. Phlebitis
- B. Infection
- C. Infiltration
- D. Thrombosis
Correct Answer: C
Rationale: The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and insert a new IV. All the remaining options are likely to be accompanied by warmth at the site.
A client diagnosed with angina pectoris appears to be very anxious and states, 'So, I had a heart attack, right?' Which response should the nurse make to the client?
- A. No. That is not why you are hospitalized.'
- B. No, but there could be some minimal damage to your heart.'
- C. No, not this time and we will do our best to prevent a future heart attack.'
- D. No, but it's necessary to monitor you and control or eliminate your pain.'
Correct Answer: D
Rationale: Angina pectoris occurs as a result of an inadequate blood supply to the myocardium causing pain; managing the condition will help address the client's pain. The nurse will want to correct the client's misconception regarding a heart attack while addressing the client's concerns. Option 1 does not address the client's concerns. Option 2 is not correct because angina involves interrupted blood supply but does not result in cardiac tissue damage. Neither the nurse nor the primary health care provider can guarantee that a heart attack will not occur as option 3 seems to indicate.
When responding to the call bell, the nurse finds the client lying on the floor beside the bed. After a thorough assessment and appropriate care, the nurse completes an incident report. How should the incident be described in the report?
- A. The client fell out of bed and was found on the floor.
- B. The client fell while climbing over the bed's side rails.
- C. The client was found lying on the floor beside the bed.
- D. The client was restless and fell while getting out of bed.
Correct Answer: C
Rationale: The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only option that describes the facts as observed by the nurse. All the remaining options are interpretations of the situation and are not factual data as observed by the nurse.
The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority?
- A. Directing the discussions so that teaching needs are met
- B. Focusing directly on the client's message regarding needs
- C. Reflecting only facts related to the client's expressed concerns
- D. Reacting to the client's responses in a matter-of-fact, professional manner
Correct Answer: B
Rationale: For effective communication, the nurse uses active listening and assesses for verbal and nonverbal communication to receive the client's intended message, thus creating an environment in which the client feels comfortable expressing feelings. An authoritarian approach is directive and not permissive, and it is unlikely to create an environment for the free exchange of thoughts and ideas. Reflecting facts only is a barrier to effective communication because subjective information can also provide a stimulus for effective communication. Reacting in a matter-of-fact manner can be an ineffective strategy for facilitating communication.