Nokea
Why is empathetic listening important during nurse-client communication?
- A. It helps in building trust and understanding.
- B. It ensures compliance with medical advice.
- C. It facilitates reaching the goals of a client.
- D. It avoids overwhelming a client with new information.
Correct Answer: A
Rationale: Empathetic listening allows the nurse to understand the client's concerns deeply, which strengthens the therapeutic relationship and improves care outcomes.
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A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.
On assessment of a patient’s learning needs, the nurse determines that a patient taking potassium-wasting diuretics does not know what foods are high in potassium. What is an appropriate nursing diagnosis for this patient?
- A. Risk for cardiac dysrhythmias related to low potassium intake
- B. Deficient knowledge related to not knowing what foods are high in potassium
- C. Imbalanced nutrition: less than body requirements related to lack of intake of potassium-rich foods
- D. Deficient knowledge related to lack of interest regarding dietary requirements when taking diuretics
Correct Answer: B
Rationale: The correct answer is 'Deficient knowledge related to not knowing what foods are high in potassium.' This nursing diagnosis directly addresses the identified learning need. While other options may be indirectly relevant, the primary issue here is the patient's lack of knowledge about potassium-rich foods.
A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?
- A. Administer oxygen at 2 liters per minute via nasal cannula.
- B. Assess the client's vital signs including oxygen saturation.
- C. Notify the Rapid Response Team immediately.
- D. Place the client in a high Fowler's position.
Correct Answer: D
Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress.
Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
Correct Answer: B
Rationale: Step-by-step rationale:
1. Hypertension is a modifiable risk factor as it can be controlled through lifestyle changes and medication.
2. Age is a non-modifiable risk factor, as it naturally increases the risk of coronary artery disease.
3. Obesity is a modifiable risk factor, as weight management through diet and exercise can reduce the risk.
4. Smoking is a modifiable risk factor, as quitting smoking can significantly reduce the risk.
Summary:
B is correct as it is a modifiable risk factor that can be actively managed. A, C, and D are incorrect as age is non-modifiable and obesity and smoking are modifiable but were not selected as correct options.
A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct Answer: A
Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection.
Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.