A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

"You are making progress in your treatment plan."

"You should call your partner to discuss this."

"It must be very frustrating for you to be here."

"It would be best to discuss your feelings with your provider."

Answer and Explanation

The Correct Answer is C

A. "You are making progress in your treatment plan." While this response provides positive reinforcement, it doesn't address the client's feelings of frustration or desire to go home, potentially invalidating their emotions.

B. "You should call your partner to discuss this." Suggesting that the client call their partner shifts the focus away from their feelings and may not provide the immediate emotional support they need.

C. "It must be very frustrating for you to be here." This response acknowledges the client's feelings and validates their frustration. It opens the door for further discussion about their emotions, helping the client feel heard and understood.

D. "It would be best to discuss your feelings with your provider." This response may dismiss the client's current feelings by directing them away from the nurse, who is present and capable of providing support. It is important to validate the client's feelings first.

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Correct Answer is C

Explanation

A) A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities: While this client requires assessment, their condition is not immediately life-threatening. Orthostatic hypotension and edema need to be evaluated, but they are not acute emergencies.

B) A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F): This client needs attention due to the infection and fever, but it is not as critical as the potential cardiac event presented in option C.

C) A client who has left shoulder pain and S-T elevation on a 12-lead ECG: This client is exhibiting signs that may indicate an acute myocardial infarction (heart attack). S-T elevation on an ECG is a significant finding and suggests that this client could be experiencing a serious cardiac event, making it the priority for assessment.

D) A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10: While this client is in pain and requires care, the priority in emergency situations is often given to conditions that are life-threatening, such as those related to cardiac function. Therefore, this client can be assessed after addressing the potential cardiac emergency.

A. Apply petroleum jelly to soothe the mucous membranes. B. Clean the equipment with an alcohol-based cleaning product. C. Avoid using nail polish remover around the client. D. Use synthetic fabrics for the client's bedding.

Correct Answer is C

Explanation

A) Apply petroleum jelly to soothe the mucous membranes: This is not advisable, as petroleum jelly is flammable and can pose a risk when using oxygen. Instead, a water-based lubricant is safer for mucous membranes.

B) Clean the equipment with an alcohol-based cleaning product: Alcohol is flammable and not recommended for cleaning oxygen equipment. Mild soap and water are more suitable for maintaining cleanliness.

C) Avoid using nail polish remover around the client: This is the correct answer. Nail polish remover often contains acetone, which is flammable and should be avoided in environments where oxygen is in use to prevent fire hazards.

D) Use synthetic fabrics for the client's bedding: This is incorrect. Natural fabrics like cotton are preferred because synthetic fabrics can create static electricity, increasing the risk of fire in the presence of oxygen.

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A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

Nursing Test Bank

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