which response would the nurse make when a client moans softly oh no im next they couldnt protect him and they cant protect me after learning a recent which response would the nurse make when a client moans softly oh no im next they couldnt protect him and they cant protect me after learning a recent
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Nursing Elites

NCLEX NCLEX-RN

Psychosocial Integrity NCLEX PN Questions

1. Which response would the nurse make when a client moans softly, 'Oh no, I’m next. They couldn’t protect him, and they can’t protect me,' after learning a recently discharged client committed suicide?

Correct answer: ''You seem to be afraid that you’ll hurt yourself.''

Rationale: The nurse would make the statement, 'You seem to be afraid that you'll hurt yourself.' This response acknowledges the client's emotional distress and opens up the opportunity for the client to discuss their feelings, showing empathy and understanding. Choice A, 'The other person was a lot sicker than you are,' dismisses the client's emotions and fails to address the underlying fear of self-harm. Choice C, 'That was different. He was at home, but you’re here,' invalidates the client's concerns and does not encourage further discussion. Choice D, 'There’s no need to worry. You have a better support system,' offers false reassurance and does not address the client's expressed fear, missing an opportunity for therapeutic communication.

2. How does shock typically progress?

Correct answer: Compensated to hypotensive shock in hours and hypotensive shock to cardiac arrest in minutes

Rationale: Shock typically progresses from a compensated state to hypotensive shock over a period of hours. In the compensated phase, the body is trying to maintain perfusion. It is crucial to identify and intervene during this phase to prevent progression to hypotensive shock, where blood pressure drops significantly. If not promptly managed, hypotensive shock can rapidly deteriorate into cardiac arrest in minutes due to inadequate perfusion to vital organs. Choices B, C, and D are incorrect as they do not follow the typical progression of shock stages as seen in clinical practice. Understanding the stages of shock and their timeframes is crucial for early recognition and appropriate intervention to prevent further deterioration.

3. The nurse develops a goal that makes a client feel as if they are engaging in a competition. Which type of motivation is the nurse using in this situation?

Correct answer: Power motivation

Rationale: The nurse is using power motivation in this situation. Power-motivated individuals tend to have assertive and aggressive behavior. By designing goals that make clients feel like they are in a competition, the nurse appeals to their need for power and accomplishment, even when they are competing against themselves. Affiliative motivation is characterized by nonassertive behavior and dependence on others, which is not applicable here. Avoidance motivation focuses on anxiety, fear of failure, and phobias, which are not relevant to the scenario. Achievement motivation does not involve aggressive behavior or the need for competition, making it an incorrect choice for this scenario.

4. Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices?

Correct answer: The medication will prevent irritation of the enlarged veins.

Rationale: The correct answer is: 'The medication will prevent irritation of the enlarged veins.' Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acidic gastric contents. While ranitidine can decrease the risk of peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, the primary purpose of H2-receptor blockade in this patient is to prevent irritation and bleeding from the varices, not the other listed effects.

5. The physician has decided to perform a thoracentesis based on Mr. R's assessment. Which of the following actions from the nurse is most appropriate?

Correct answer: Instruct the client not to talk during the procedure

Rationale: The correct answer is to instruct the client not to talk during the procedure. This is important to prevent air from being drawn into the pleural space during the thoracentesis. Choice B is incorrect because the client should be sitting upright or slightly leaning forward during the procedure to facilitate access to the pleural space. Choice C is incorrect as the nurse should not perform the thoracentesis procedure, which involves inserting a needle into the pleural space - this is the physician's responsibility. Choice D is incorrect as connecting the needle to suction to remove fluid is not the appropriate procedure for a thoracentesis. Thoracentesis is typically done to remove fluid or air for diagnostic or therapeutic purposes, not to connect to suction to remove fluid that has collected in the pleural space.

Similar Questions

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The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?
Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?
When caring for a patient who speaks a different language and an interpreter is unavailable, which action by the nurse is most appropriate?
For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?

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