A nurse is caring for an adult patient who has had a minor motor ...

[cnetterville]

A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health history reveals that the patient is currently in the process of obtaining a divorce.
 
  Which of the following actions should the nurse take? (Select all that apply.) a. Agree upon and make time for the patient to talk.
  b. Use active listening skills and therapeutic touch as appropriate.
  c. Teach stress reduction strategies.
  d. Inform patient that stressed individuals are more likely to have accidents.
  e. Agree to witness telephone conversations with separated husband.
  f. Refer the patient to the nurse's church marriage counselor.

Question 2

The client is admitted to the medical centre with a diagnosis of right-sided heart failure. In assessment of this client, which of the following does the nurse expect to find?
 
  a. Dyspnea
  b. Confusion
  c. Dizziness
  d. Peripheral edema

[manuelcastillo]

Answer to Question 1

A, B, C, D
Agreeing and making time for conversation, using active listening skills and therapeutic touch, teaching stress reduction strategies, and informing the patient of the risk to health associated with stress are interventions that are within the nurse's scope of practice. Agreeing to witness a telephone conversation could draw the nurse into divorce proceedings when the focus should be on the patient and his health. Referring the patient to the nurse's church counselor without a specific request from the patient may not take into consideration cultural care and could be considered unprofessional. If the patient requested a marriage counselor, a better solution would be to provide a referral to social services that may include a list of possible counselors from which the patient could choose.

Answer to Question 2

D
Peripheral edema is an expected assessment finding in the client diagnosed with right-sided heart failure.
Dyspnea is an expected assessment finding in the client diagnosed with left-sided heart failure.
Confusion is a symptom of hypoventilation.
Dizziness is an expected assessment finding in the client experiencing hypoxia.

[cnetterville]

TYSM

[helenmarkerine]

Gracias!