Tüm alıştırma soruları

Match each client scenario or statement with the most appropriate therapeutic communication technique the nurse should utilize.

A charge nurse is managing the milieu of an acute behavioral health unit. A client diagnosed with schizophrenia is experiencing severe command hallucinations, pacing aggressively in the main corridor, and loudly accusing peers of being 'undercover agents.' Several other clients are visibly frightened and are gathering nearby to watch the situation. Which immediate environmental management strategies are most appropriate for the nurse to implement? (Select all that apply.)

The nurse is caring for a client on the inpatient psychiatric unit who is actively experiencing auditory hallucinations. Which actions should the nurse implement? Select all that apply.

A young adult client is brought to the emergency department via police after being found wandering in traffic. The client is currently in an examination room, highly agitated, hyperventilating, and throwing medical supplies onto the floor. When staff approach, the client screams, 'They are coming to take me away!' Which of the following initial actions by the nurse are appropriate? Select all that apply.

A client on the inpatient psychiatric unit is experiencing severe anxiety. They are pacing rapidly, hyperventilating, and frantically stating, "I feel like I am going to die!" Which of the following is the priority nursing action?

Fifteen minutes after the initiation of a packed red blood cell (PRBC) transfusion, a client reports sudden severe lower back pain and develops chills. Which action must the nurse take first?

A nurse is caring for an older adult client who is actively dying in a hospice unit. The client is unresponsive, experiencing noisy respiratory secretions, and exhibiting restlessness. Which actions should the nurse take? Select all that apply.

A client receives a new diagnosis of amyotrophic lateral sclerosis (ALS) from the neurologist. Shortly after the discussion, the nurse enters the room and the client says, "The doctor is just being overly dramatic. I just have a pinched nerve from working in the garden, and it will heal on its own with some rest." Which initial response by the nurse is the most therapeutic?

A nurse on the maternity unit is caring for a couple who just experienced an unexpected stillbirth at 38 weeks of gestation. The parents are crying softly and averting their gaze from the delivery area. Which action should the nurse take to best facilitate the initial stages of the grieving process?

The nurse is preparing to administer an intermittent enteral feeding to a client via a nasogastric tube. In what order should the nurse perform the following actions? (Arrange the steps in the correct sequence from first to last.)

A nurse is preparing to obtain a blood specimen for laboratory testing from a client's multi-lumen central venous catheter (CVC). The selected lumen currently has a continuous infusion of 0.9% sodium chloride. Arrange the following steps for obtaining the blood sample in the correct clinical sequence.

An older adult client is admitted to the intensive care unit (ICU) following major surgery. The client is continuously exposed to monitor alarms, bright overhead lights, and frequent staff interactions. On the second day, the client becomes severely agitated, disoriented to time and place, and begins pulling at their intravenous (IV) lines. Which action should the nurse take first to address the client's current condition?

During a morning assessment, a client with newly diagnosed end-stage liver disease refuses their prescribed oral medications. The client crosses their arms, looks away, and states, "I am not swallowing another pill. My body is shutting down anyway, so delaying the inevitable is just a waste of everyone's time." Which response by the nurse demonstrates the most appropriate therapeutic communication technique?

A community health nurse is conducting a home visit for an 88-year-old client who was recently discharged from the hospital. The client's family reports that the client has developed new-onset urinary incontinence and a decreased appetite over the past 48 hours. The nurse is accompanied by a home health aide (UAP). Which of the following actions by the nurse indicate appropriate practice? Select all that apply.

A client is receiving a continuous intravenous (IV) infusion of unfractionated heparin for the treatment of a pulmonary embolism. Routine morning laboratory results reveal a sudden decrease in the client's platelet count from 180,000/mm³ (180 x 10^9/L) on admission to 60,000/mm³ (60 x 10^9/L) today. The client reports no active bleeding. Which action is the priority for the nurse to take?

A client in an outpatient neurology clinic has just been informed of a progressive, life-altering neurological diagnosis. The client sits rigidly in the chair, staring blankly at the wall, and states in a flat tone, 'My future is gone. There is no point in trying to go on anymore.' Which action is the priority for the nurse to take?

An older adult client is admitted to the intensive care unit (ICU) for the management of severe sepsis and requires mechanical ventilation. On the third day of admission, the client develops acute, fluctuating confusion, severe inattention, and psychomotor agitation. The client appears terrified of the ventilator sounds and makes repeated attempts to remove the endotracheal tube. Based on the client's acute sensory and perceptual alterations, which nursing interventions are most appropriate? Select all that apply.

A 78-year-old client is 2 days postoperative following a right total hip arthroplasty (posterior approach). The client has a history of chronic obstructive pulmonary disease (COPD) and a recent stroke resulting in dysphagia. They are receiving continuous enteral feeding via a nasogastric (NG) tube. The client is intermittently confused and attempting to pull at the NG tube. Which nursing action is most appropriate when providing basic care and comfort?

A client admitted with diabetic ketoacidosis (DKA) is receiving a continuous intravenous (IV) infusion of regular insulin at $0.1\text{ units/kg/hr}$. The client's baseline serum potassium was $5.4\text{ mEq/L}$ and blood glucose was $680\text{ mg/dL}$. Four hours later, the current blood glucose is $245\text{ mg/dL}$, and the cardiac monitor reveals new-onset premature ventricular contractions and prominent U waves. The current primary IV fluid is $0.9\%$ sodium chloride infusing at $150\text{ mL/hr}$. Based on these findings, which of the following is the priority nursing action?

A healthcare provider prescribes an intravenous infusion of dopamine for a client diagnosed with cardiogenic shock. The prescribed dose is $10 \text{ mcg/kg/min}$. The client weighs $176 \text{ lb}$. The pharmacy dispenses a pre-mixed bag containing $800 \text{ mg}$ of dopamine in $250 \text{ mL}$ of $5\%$ dextrose in water. The nurse should set the intravenous infusion pump to deliver how many mL/hr? (Record your answer as a whole number).