A client, age 40, is admitted for a surgical biopsy of a suspicious lump in her left breast. When the nurse comes to take her to surgery, she is tearfully finishing a letter to her two children. She tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic?
A. "In case anything goes wrong? What are your thoughts and feelings right now?"
B. "I can understand that you're nervous, but this really is a minor procedure. You'll be back in your room before you know it."
C. "Try to take a few deep breaths and relax. I have some medication that will help."
D. "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours."
Ans: A. "In case anything goes wrong? What are your thoughts and feelings right now?"
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a. discuss the patient's wishes. b. finish the procedure quickly. c. stop the procedure immediately. d. tell the patient that the procedure is almost done.
A patient was admitted into the critical care unit 3 days ago. She has just been weaned from mechanical ventilation. She suddenly becomes confused, seeing nonexistent animals in her room and pulling at her gown. You suspect this patient is
a. experiencing delirium or "ICU psychosis." b. experiencing confusion caused by increased hypoxia. c. hypocalcemic. d. acting out to receive the attention she was getting while intubated.
When nursing actions cause the nurse to violate the personal space of the patient, the nurse can reduce the discomfort of the patient by:
a. approaching the interaction in a professional manner. b. distracting the patient with jokes and humor. c. asking another nurse to be present at the bedside. d. assuring the patient that all people dislike invasion of personal space.
Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3½ to 4 minutes. The nurse would report this as:
a. First stage, latent phase. b. First stage, active phase. c. First stage, transition phase. d. Second stage, latent phase.