A client's family reports that the client does not hear well. The client becomes angry and defensive and denies having a hearing problem. The best response by the nurse would be
a. "It seems like it's hard to listen to your family when you don't agree with them."
b. "My father has a hearing aid and is really glad he got it."
c. "There's nothing to be ashamed about having poor hearing."
d. "Why don't you believe what your family is saying?"
A
This response opens up an avenue for communication in which the client's feelings are acknowledged. The client must go through the steps of grieving before accepting the hearing loss and beginning any type of program to help with hearing. Option b might be a helpful thing to say when a client is considering a hearing aid, but at this point would diminish the client's feelings, as does option c. Option d is argumentative.
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What will be an ideal response?
A mother of two children, an 8-year-old and a 10-year-old, tells you that her husband has recently been deployed to the Middle East
The mother is concerned about the children's constant interest in watching TV news coverage of activities in the Middle East. The most appropriate suggestion for the nurse to make to this mother would be: 1. "Allow the children to watch as much television as they want. This is how they are coping with their father's absence." 2. "It will just take some time to adjust to their father's absence, then everything will return to normal." 3. "The less that you discuss this, the quicker the children will adjust to their father's absence. Try to keep them busy and use distractions to keep their mind off of it." 4. "Spend time with your children, and take cues from them about how much they want to discuss."
When auscultating the anterior thorax of a pregnant woman, the nurse notices the presence of a murmur over the second, third, and fourth intercostal spaces. The murmur is continuous but can be obliterated by pressure with the stethoscope
or finger on the thorax just lateral to the murmur. The nurse interprets this finding to be: a. Murmur of aortic stenosis. b. Most likely a mammary souffle. c. Associated with aortic insufficiency. d. Indication of a patent ductus arteriosus.