A client diagnosed with angina pectoris appears to be very anxious and states, "So I had a heart attack, right?" Which response should the nurse make to the client?
"Yes, that's why you are hospitalized."
"Yes, but it will never happen again."
"No, but it is necessary to monitor, control, and eliminate your chest pain."
"No, it is normal to feel chest pain."
The Correct Answer is C
Choice A reason: Telling the client that they are hospitalized due to a heart attack when it is not the case can cause unnecessary anxiety and fear. It is important to provide accurate information and reassurance.
Choice B reason: Stating that it will never happen again is unrealistic and provides false reassurance. It is important to focus on managing the client's condition and reducing the risk of future episodes.
Choice C reason: Explaining that the client did not have a heart attack but emphasizing the importance of monitoring and managing chest pain provides accurate information and reassurance. It helps reduce the client's anxiety and provides a clear plan of action.
Choice D reason: Saying it is normal to feel chest pain without further explanation can cause confusion and anxiety. It is important to clarify that chest pain needs to be monitored and managed to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.
Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.
Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.
Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.
Correct Answer is D
Explanation
Choice A reason: Bright light sensitivity is a common side effect following cataract surgery and can be managed with appropriate measures such as wearing sunglasses. It does not necessarily indicate a complication requiring immediate reporting.
Choice B reason: Difficulty seeing with a patch on one eye and fear of falling are valid concerns, but they do not necessarily indicate an immediate complication that requires urgent reporting to the healthcare provider.
Choice C reason: Eye itching is common after cataract surgery, and the client should be advised not to rub the eye to prevent infection or damage. This comment does not indicate a severe complication that needs immediate reporting.
Choice D reason: Severe eye pain that the client cannot stand is a potential sign of a serious complication, such as increased intraocular pressure, infection, or other postoperative issues. This requires immediate attention from the healthcare provider to prevent further complications and ensure the client's safety.
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