A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
Answer(s): A
(A) This intervention will help to clarify any misunderstandings about the surgery and give the client an opportunity to verbalize concerns about the surgery. (B) Distractors will not alleviate the preoperative anxiety that the client is experiencing. This response actually denies the client's anxiety. (C) This intervention is false assurance and denies that anxiety is a normal response to the threat of surgery. (D) Psychological responses are not directly related to the extent of the surgery, because they are influenced by the client's past experiences.
A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:
Answer(s): B
(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.
A client who has gout is most likely to form which type of renal calculi?
Answer(s): C
(A) The presence of urinary tract infection is a factor in the formation of struvite stones. (B) Staghorn calculi is the other name for struvite stones associated with urinary tract infection. (C) Clients who have gout form uric acid stones. (D) Clients who have increased urinary excretion of calcium form calcium stones.
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