A nurse is caring for a client who is newly diagnosed with cancer. Which of the following nursing interventions to maximize successful coping to the treatment plan should the nurse initiate at this time? (SELECT ALL THAT APPLY)

Encourage the client to express feelings and concerns

Tell the client what coping skills he should use

Assist the client with time management and priorities

Allow the client input into the treatment plan

Provide extensive instructions about the client's treatment plan and prognosis

Answer and Explanation

Correct Answer : A,C,D

A. This intervention promotes emotional expression and allows the client to verbalize their fears, worries, and uncertainties related to the cancer diagnosis. Encouraging the client to express their feelings fosters a sense of emotional support, validation, and empathy, which are essential for coping with the emotional impact of the diagnosis.
C. Cancer diagnosis and treatment often involve multiple appointments, tests, and treatments, which can be overwhelming for the client. Assisting the client with time management and priorities can help alleviate stress and enhance coping by providing structure, organization, and support in managing the demands of the treatment plan and daily life responsibilities.
D. Involving the client in decision-making and allowing them input into the treatment plan empowers the client and promotes a sense of control and autonomy over their care. Collaborative decision-making enhances the client's engagement, adherence, and satisfaction with the treatment plan, which are essential for successful coping and treatment outcomes.
B. Telling the client what coping skills to use may not be the most effective approach, as it disregards the individuality of the client's coping mechanisms and preferences. Instead, the nurse should explore with the client what coping strategies they have used in the past and provide guidance and support in identifying and implementing effective coping strategies that align with the client's needs and preferences.
E. Providing extensive instructions about the treatment plan and prognosis is important for promoting understanding, informed decision-making, and adherence to the treatment plan. However, the timing and amount of information should be tailored to the client's readiness and preferences. Too much information too soon may overwhelm the client and hinder coping, while inadequate information may lead to uncertainty and anxiety. Therefore, the nurse should provide information in a clear, empathetic, and supportive manner, ensuring that the client's informational needs are met while respecting their emotional readiness.

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Correct Answer is C

Explanation

C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.

A. Stop the infusion immediately B. Document the findings in a nurse's note C. Flush the catheter with 3ml normal saline D. Remove the catheter and apply pressure to the site

Correct Answer is A

Explanation

A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.

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A nurse is caring for a client who is newly diagnosed with cancer. Which of the following nursing interventions to maximize successful coping to the treatment plan should the nurse initiate at this time? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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