A client presents to the emergency department (ED reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

Share personal values to put the client at ease.

Get the most difficult questions over with first.

Ask questions in a vague, non-specific format.

Begin with questions that are less sensitive in nature.

Answer and Explanation

The Correct Answer is D

A.   Share personal values to put the client at ease: Sharing personal values may not be appropriate and could potentially alienate the client or make them feel judged.
B.   Get the most difficult questions over with first: Starting with difficult questions may increase the client's defensiveness and resistance to sharing information.
C.   Ask questions in a vague, non-specific format: Being vague may not elicit the necessary information and could lead to misunderstandings or incomplete responses.
D.   Begin with questions that are less sensitive in nature: Starting with less sensitive questions helps build rapport and trust with the client before addressing more sensitive topics like domestic violence. It allows the client to feel more comfortable and may increase the likelihood of obtaining accurate information.

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Correct Answer is C

Explanation

A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease
experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote
relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B. Place an indwelling urinary catheter and institute strict intake and output measurements. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Secure client consent for coronary angiography and percutaneous coronary intervention.

Correct Answer is C

Explanation

A. Evaluating upper and lower extremities for perfusion, pulse volume, and pitting edema is important in assessing peripheral perfusion, but the priority action in this scenario is to initiate treatment for a suspected myocardial infarction.
B. Placing an indwelling urinary catheter and instituting strict intake and output measurements is not the priority action in this scenario. The client's symptoms and history suggest a cardiac event requiring immediate intervention.
C. Administering four 81 mg aspirin tablets (324 mg total) as soon as possible is the priority action for a client presenting with chest pain suggestive of acute coronary syndrome. Aspirin helps to prevent platelet aggregation and reduce the risk of clot formation.
D. Securing client consent for coronary angiography and percutaneous coronary intervention may be necessary but is not the immediate priority. The client needs immediate treatment to alleviate symptoms and stabilize the condition.

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A client presents to the emergency department (ED reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?

Correct Answer is C

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

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