A nurse is caring for a client whose partner has a terminal diagnosis. Which of the following statements made by the client indicates effective coping?

"I cook my partner's favorite foods."

"I make a list of all the things I need to do."

"I have lunch with my friends once a week."

"I am unable to fall asleep right away."

Answer and Explanation

The Correct Answer is C

A. "I cook my partner's favorite foods.": Preparing meals can be a way to show love and care, but it does not necessarily indicate effective coping. It may serve as a distraction, but it does not address emotional or social well-being.

B. "I make a list of all the things I need to do.": Creating lists can help with organization, but it does not directly reflect emotional coping. It may indicate a focus on tasks rather than emotional processing or seeking support.

C. "I have lunch with my friends once a week.": Maintaining social connections is a sign of effective coping, as it provides emotional support and an opportunity to share feelings. Engaging in enjoyable activities outside of caregiving responsibilities helps reduce stress.

D. "I am unable to fall asleep right away.": Difficulty sleeping is a common response to stress but suggests ongoing emotional distress rather than effective coping. Persistent sleep disturbances may require further assessment and support.

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Correct Answer is D

Explanation

A. "Use the incentive spirometer every 4 hours.": Incentive spirometry is typically recommended every 1 to 2 hours while awake to promote lung expansion and prevent atelectasis. Less frequent use may not provide adequate lung re-expansion, especially after surgery.

B. "Avoid coughing during and after the session.": Coughing is encouraged after using an incentive spirometer to help clear secretions and prevent respiratory complications such as pneumonia. Suppressing a cough can lead to mucus retention and increased risk of infection.

C. "Remove the mouthpiece and exhale quickly.": The client should exhale normally before using the spirometer, then inhale slowly through the mouthpiece to maximize lung expansion. Rapid exhalation does not promote adequate alveolar inflation.

D. "Place the mouthpiece in your mouth and inhale slowly.": Slow, deep inhalation through the spirometer allows for maximum lung expansion, reducing the risk of atelectasis. The client should maintain a steady breath to ensure optimal lung inflation and hold it for a few seconds before exhaling.

A. A palpable thrill at the fistula site B. Hyperglycemia C. Altered mental status D. Decrease in weight

Correct Answer is C

Explanation

A. A palpable thrill at the fistula site: A palpable thrill is a normal finding that indicates proper blood flow through the arteriovenous fistula. The absence of a thrill would be concerning, as it may suggest clotting or dysfunction of the vascular access.

B. Hyperglycemia: Hemodialysis does not typically cause hyperglycemia. Clients with diabetes may experience fluctuations in blood glucose levels, but dialysis itself is more commonly associated with hypoglycemia due to the removal of glucose from the bloodstream.

C. Altered mental status: Neurological changes such as confusion, restlessness, or decreased responsiveness may indicate dialysis disequilibrium syndrome (DDS). This complication results from rapid fluid and solute shifts, leading to cerebral edema. It is a serious condition requiring immediate intervention.

D. Decrease in weight: A decrease in weight following hemodialysis is expected due to fluid removal. Clients are weighed before and after dialysis to monitor fluid balance, and weight loss after treatment indicates effective fluid removal rather than a complication.

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A nurse is caring for a client whose partner has a terminal diagnosis. Which of the following statements made by the client indicates effective coping?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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