Exam 4 Nursing 142X

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem?

• Anxiety related to the need to make lifestyle changes

• Boredom resulting from having already learned the material

• An attempt to ignore or deny the need to make lifestyle changes

• Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

Answer explanation

Rationale:
Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.

Clinical Judgment/Cognitive Skill(s): Analyze Cues

Priority Concepts: Stress and Coping, Patient Education

A client with severe psoriasis has a problem of chronic low self-esteem. The nurse would incorporate which nursing action when working with this client?

• Listening attentively

• Keeping communications brief

• Approaching the client in a formal manner

• Avoiding looking at the affected skin areas

Answer explanation

Rationale:
Clients with chronic skin disorders may experience chronic low self-esteem because of the disorder itself and possible rejection by others. The nurse demonstrates acceptance of the client by using a quiet, unhurried manner and by using appropriate visual contact, facial expression, and therapeutic touch. Communications that seem brief and formal may reinforce the feelings of rejection, as well as avoidance of looking at the affected skin areas.

Clinical Judgment/Cognitive Skill(s): Generate Solutions

Priority Concepts: Stress and Coping, Communication

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client and family?

• Discouraging the family from touching the client

• Explaining equipment and procedures on an ongoing basis

• Ensuring adherence to visiting hours to ensure the client's rest

• Encouraging the family not to "give in" to their feelings of grief

Answer explanation

Rationale:
Families often need assistance to cope with the illness of a loved one. The nurse would explain all equipment, treatments, and procedures and would supplement or reinforce information given by the primary health care provider. Family members need to be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable. The nurse would allow the family to stay with the client to the extent possible and would encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.

Priority Concepts: Stress and Coping, Family Dynamics

Clinical Judgment/Cognitive Skill(s): Generate Solutions

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid–base disturbance?

• Metabolic acidosis

• Metabolic alkalosis

• Respiratory acidosis

• Respiratory alkalosis

Answer explanation

Rationale:
The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

Content Area: Foundations of Care: Acid-Base

Priority Concepts: Acid-Base Balance, Clinical Judgment

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

• Bradycardia and hyperactivity

• Decreased respiratory rate and depth

• Headache, restlessness, and confusion

• Bradypnea, dizziness, and paresthesias

Answer explanation

Rationale:
When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

Content Area: Foundations of Care: Acid-Base

Priority Concepts: Acid-Base Balance, Clinical Judgment

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted?

• Rhonchi

• Wheezes

• Crackles in the bases

• Crackles throughout the lung fields

Answer explanation

Rationale:
Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields.

Priority Concepts: Gas Exchange, Clinical Judgment

Which method would the nurse use to dispose of printed patient information

• Rip several times and place in a standard trash can

• Place in the patient's paper-based chart

• Place in a secure canister marked for shredding

• Burn the documents

Answer explanation

Rationale:

Confidential patient information should be shredded. It is generally collected in large, secure containers and shredded at scheduled times. Ripping the information or placing it in a paper chart does not ensure patient confidentiality. Burning paper is a fire hazard and is not allowed on nursing units.