a nurse is caring for a 60 year old man who is scheduled to have coronary bypass surgery in the morning he tells the nurse that he is afraid that he w
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HESI PN Exit Exam 2024 Quizlet

1. A nurse is caring for a 60-year-old man who is scheduled to have coronary bypass surgery in the morning. He tells the nurse that he is afraid that he will die and he is scared of the surgery. What is the best reply for this nurse to give him?

Correct answer: C

Rationale: The best reply for the nurse to give the patient is option C: 'You’re scared?' This response reflects empathy and understanding, acknowledging the patient's feelings of fear. By directly addressing the patient's emotions, the nurse encourages further expression of concerns, which is crucial in providing emotional support. Choices A and D may come off as dismissive of the patient's feelings by downplaying his fear or shifting the focus to others' experiences. Choice B, although acknowledging the patient's fear, does not actively engage with the patient's emotions or encourage further discussion.

2. When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the nurse to perform instead of assigning to a UAP?

Correct answer: C

Rationale: During a fire emergency in a long-term care facility, the most critical task for the nurse is to identify the method for transporting and evacuating each resident. This task requires quick decision-making and critical thinking, which are essential in ensuring the safety and well-being of the residents. Closing the doors to residents' rooms (Choice A) can help contain the fire but should not be the nurse's top priority. While offering comfort and reassurance (Choice B) is important, the immediate focus should be on ensuring safe evacuation. Providing blankets (Choice D) is also important but comes after ensuring safe transportation and evacuation plans are in place.

3. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the nurse plan to include in the child's plan of care?

Correct answer: C

Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. Monitoring blood pressure frequently is crucial in managing glomerulonephritis, as hypertension is a common complication during the acute edematous phase. Choice A is incorrect as it does not address the specific needs of a child with glomerulonephritis. Choice B is incorrect as excessive activity may not be suitable during the acute phase, as rest and monitoring are more important. Choice D is incorrect as the focus should be on monitoring vital signs rather than meal options.

4. The nurse is assisting the recreational director of a long-term care facility in planning outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

Correct answer: B

Rationale: A tea party in the courtyard provides a social and physical activity suitable for wheelchair-bound older residents who are mentally alert. It offers an opportunity for social interaction, enjoyment of the outdoors, and participation in a physical activity without the need for extensive mobility. An open-air concert may not provide the same level of social interaction or physical engagement as a tea party. A team ring-toss competition may be physically challenging for wheelchair-bound residents. A picnic in the park could present challenges related to accessibility and might not foster the same level of social interaction as a tea party in a more contained courtyard setting.

5. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.

Similar Questions

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