Unless previous arrangements have been made for chiropractic care or craniosacral therapeutic massage, the nurse should engage the client in a discussion of what treatments have been helpful outside of the hospital. This is best done before the full migraine symptoms present. It is demeaning and opinionated to dismiss chiropractors as not "real doctors". Offering a medication may be premature without a full migraine assessment history. The nurse must also have full knowledge of all available medication orders to offer medication at this point. Having pain is not a reason to deny a client from having a visitor. Question 44 A client admitted for rhinoplasty posts a "do not disturb" sign on the door of the room. The nurse quietly knocks on the door, and enters to find the client seated on the bed in a yoga-like pose, apparently under some type of trance. The nurse recognizes that the client: You Selected: is practicing yoga to help relax. Correct response: is practicing yoga to help relax. Rationale: The nurse recognizes that the client planned a meditation or self-hypnosis session to help the client to relax before surgery. The nurse should not jump to conclusions that the client is using drugs. There is no suggestion of seizure activity. There is no indication for discharging this client because of this behavior. The nurse should reinforce that coordination with staff would help insure the client's privacy. Question 45 A client reports on admission for a bronchoscopy that the client has been managing hypertension for the past year with a type of biofeedback device. What is the nurse’s best response? You Selected: “Explain to me how it works for you.” Correct response: “Explain to me how it works for you.” Rationale: The nurse’s best response is to demonstrate a willingness to learn about this treatment and how it works for this client. Asking the client also provides an opportunity for the nurse to assess the client’s understanding of the illness and this treatment device. Offering comments on saving money, or other uses for biofeedback will not help engage the client in a therapeutic discussion. Challenging the client to report the physician’s feedback may provide helpful feedback, but will also not allow the nurse to assess the client’s knowledge and experience with this treatment for the hypertension. Question 46 A young Hispanic woman is admitted for surgical treatment of genital lesions. What should the nurse identify as an important part of care for this client? You Selected: The client is embarrassed and ashamed of her symptoms. Correct response: Provide a chaperone or assistant in her care whenever possible. Rationale: It is important for the nurse to recognize that members of Hispanic cultures are often very modest, and accept a chaperone to help reassure them. The client may be embarrassed, but should not experience shame related to this disease. The family would not shun her or avoid visiting in the hospital. It is judgmental to assume this client delayed her treatment.
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- Spring '17
- mrs. Vargovich
- Nursing, Correct Response