The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:
prepare to place the client in a single room.
ask the client if they wish to speak to a spiritual advisor.
explore the possibility of suicidal thoughts with the client.
explain to the client that they will not die for a long time.
The Correct Answer is C
A. While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B. This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C. When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D. While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cryoprecipitate is indicated for low fibrinogen or clotting factor issues, but the client’s primary issue
here is anemia and thrombocytopenia.
B. FFP is used to replace clotting factors. While it could be considered in certain situations, in this case, the primary concern is the severe anemia and thrombocytopenia.
C. This is the most appropriate choice, as the patient has low hemoglobin (anemia) and a very low platelet count, both of which require packed red blood cells and platelets.
D. This combination is typically used for clotting factor issues, not anemia and thrombocytopenia.
Correct Answer is B
Explanation
A. The pacemaker wire for a DDD device is placed in the right atrium and right ventricle, not the left ventricle.
B. This is the correct description of a DDD pacemaker, which has wires in both the right atrium and right ventricle to monitor and pace both chambers when needed.
C. This is incorrect because a DDD pacemaker does not pace both ventricles.
D. This is inaccurate because a DDD pacemaker does not fire with every heartbeat; it only fires when the heart’s natural electrical activity is insufficient.
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