NCLEX-RN
Caring for a Patient Questions
Question 1 of 5
A client diagnosed with diabetes mellitus requires the immediate amputation of a leg. The client is very upset and states, 'This is the doctor's fault! I did everything that I was told to do!' When considering the grieving process, how should the nurse respond to the client's statement?
Correct Answer: C
Rationale: Anger is a stage in the grieving process and an expected response to impending loss. Usually a client directs the anger toward himself or herself, God or another spiritual being, or the caregivers; thus far the client's behavior demonstrates effective coping. Notifying the risk management department is premature, especially because the client has said nothing about legal action. Analyzing alternative treatment options and previous health care providers is likely to interfere with effective coping, and it can delay lifesaving treatment.
Question 2 of 5
The nurse has an established relationship with the family of a client whose death is imminent. Which intervention should the nurse focus on in order to help the family most effectively cope with this experience?
Correct Answer: D
Rationale: Maintaining effective and open communication among family members affected by death and grief is important to facilitate decision making and effective coping. The nurse maintains and enhances communication and preserves the family's sense of self-direction and control effectively by answering questions clearly and providing information and resources for decision making as requested by the family. Isolating the family from the client by limiting time in the client's room is inappropriate. The nurse should not provide education about coping mechanisms for family members to use because coping mechanisms directed by the nurse are unlikely to be as effective as the methods that the individuals choose for themselves. Identifying spiritual measures that work best for the dying client generalizes and does not reflect individualized care.
Question 3 of 5
A community health nurse is caring for a group of homeless people. What is the most immediate concern when planning for the potential needs of this group?
Correct Answer: D
Rationale: The question asks about the situation's most immediate concern. The initial community health concern is always attending to people's basic physiological needs of food, shelter, and clothing. Finding affordable housing and providing crisis intervention and peer support are meaningful interventions that may be completed at a later time.
Question 4 of 5
An older couple was emotionally despondent when their home was severely damaged by flooding. When planning for the couple's initial needs, what intervention should the community health nurse implement?
Correct Answer: D
Rationale: The question asks about the first thing that the nurse needs to consider when planning for the rescue and relocation of these older residents. The initial concerns of community health are always attending to people's basic needs of food, shelter, and clothing. Contacting family, addressing emotional needs, and arranging for home repairs are needs that may be addressed as needed after physiological needs are met.
Question 5 of 5
A stillborn baby was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. The registered nurse is orienting a new nurse, and has provided education on how to communicate with the family. Which statement by the new nurse indicates that teaching has been effective?
Correct Answer: A
Rationale: Nurses should be able to explore measures that assist the family with creating memories of the infant so that the existence of the child is confirmed, and the parents can complete the grieving process. The correct option identifies this measure and also demonstrates a caring and empathetic client-focused response while providing the family with the option to express their needs. Option 2 devalues the parents' feelings and is inappropriate. Option 3 is inappropriate and reflects a lack of knowledge on the nurse's part. Option 4 appears that the nurse is uncaring.