When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).
Assist the client in identification of a social support network.
Administer sedative-hypnotics as directed.
Identify stress-reducing techniques when environmental stressors cannot be controlled.
Discuss with the client factors they feel contribute to stress.
Correct Answer : A,C
These interventions help the client to cope with stress by enhancing their social support and teaching them skills to manage stressors.
Choice B is wrong because sedative hypnotics may cause dependence and do not address the underlying causes of stress.
Choice D is wrong because discussing factors that contribute to stress may increase the client’s anxiety and does not provide any solutions.
The normal range for coping is to use adaptive strategies that reduce stress and promote well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
Correct Answer is D
Explanation
Emptying the urine drainage bags at least once per shift is a task that can be delegated to unlicensed assistive personnel (UAP) assigned to a cardiac surgery unit.
This task does not require assessment, teaching, or evaluation skills that are beyond the scope of practice of UAP.
Choice A is wrong because teaching a client how to use a pillow to support an incision when coughing requires education and evaluation skills that are only within the scope of practice of licensed nurses.
Choice B is wrong because checking the pedal pulses of bed-bound clients requires assessment skills that are only within the scope of practice of licensed nurses.
Pedal pulses are important indicators of peripheral circulation and vascular status.
Choice C is wrong because ambulating the first-day postoperative clients requires assessment and evaluation skills that are only within the scope of practice of licensed nurses.
First-day postoperative clients may have complications such as bleeding, infection, or hypotension that need to be monitored by a nurse.
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