SET C ANSWERS

1) A
- The client's question reflects his thoughts about the will and how to obtain an executor, but the question
does not reveal why the client is asking the nurse to be executor, and it also does not address other
important information. In option A, the nurse seeks clarification while acknowledging the client's
statement. Most agencies do not allow a nurse to be the executor of a client's will (option B) or to witness
other legal documents to avoid conflict-of-interest charges. In addition, option C is an unsuitable
response. In option D, the nurse, who is responding with social communication, fails to regard the
potential consequences, think critically, or explore the client's motivation and needs.
2) B
- The cause of the client's confusion is bedrest and decreased sensory stimulation from a prolonged
length of stay; therefore, the best intervention is to ambulate the client in the hall to increase sensory
stimulation. Hopefully the stimulation can help to decrease the confusion. Options A and C do not address
the client's need for sensory stimulation. The nurse performs option D in preparation for ambulation while
the client is on bedrest.
3) A
- A client who receives PN is at risk for developing an essential fatty acid deficiency; however, this client's
comment requires more than a simple informational response initially. Thus, the nurse responds with
option A to assist the client with self-expression and to deal with aspects of illness and treatment. Option
B delays client self-expression and devalues the client's feelings. Options C and D provide information
only.
4) B
- The nurse uses techniques of therapeutic communication to reflect the client's statement (option B), to
redirect feelings back to the client for validation, and to focus on the client's desire to talk with the doctor.
Option A is a nontherapeutic response. Option C reinforces the client's behavior. Option D is a defensive
response, although it does provide information.
5) B
- This client is concerned about surgery and is expressing fear about the anesthesia. The therapeutic
response to the client is the one that encourages the client to express her concerns. Option A is a
stereotypical response. Option C avoids the client's concern and focuses on the nurse's personal
experience. Option D also avoids the client's concern.

6) D
- The client's statement reflects a psychosocial concern regarding his or her appearance after surgery, so
Disturbed body image is the correct option. The remaining options identify unsuitable nursing diagnoses
that are not supported by the provided client data.
7) B
- Psychosocial assessment includes client data related to psychological and social issues. Because the
CVC can create socially awkward situations and impair the client's self-concept and body image, the
nurse assesses the client for body image disturbance. The client data presented do not support assessing
the client for ineffective health maintenance. Although pain and neck range of motion are valid issues for
this client, options C and D are physiological issues.
8) B
- The nurse uses simple terms to clearly inform the client about the IV's purpose (option B). Avoiding the

client's feelings (option A) blocks client communication regarding justifiable fears and feelings related to
the IV insertion. Option C is an unethical statement for the nurse to make, because the information is
incorrect. Option D is an unsuitable statement, because the client potentially would not understand the
word "angiocatheter."
9) D
- An implanted port is subcutaneous; it is not visible, and it has no external tubing. Tubing is used when
an intravenous line is connected and the port is accessed for therapy. The remaining options do not
correct the client's confusion about the implanted port. Notifying the provider is not indicated. Inquiring
about the client's friends is a reasonable response, but it can also provide false hope that the friends will
be accepting. In addition, the nurse is likely to cause more anxiety and concern by providing information
about the catheter's subcutaneous location. Showing various central line catheters is unlikely to be
beneficial, because the client will not be using them; in addition, this can heighten client anxiety and
concerns.
10) B
- The nurse assists the client with expressing feelings and dealing with the aspects of illness and
treatment by clarifying and helping the client to focus on and explore concerns. In option A, the nurse
characterizes and classifies the feelings on the basis of an assumption. Option C provides false hope,
and option D blocks communication by giving advice.
11) D
- Reduced clarity of the client's environmental awareness can result in confusion in an older client who
was not confused before the hospital admission; thus the most important client information for the nurse
to consider when planning care is the presence of the hearing aid, because it is most likely to help the
client understand and interact properly with the environment. In addition, helping the client hear provides
for accurate follow-up client assessment data. Many factors can lead to confusion in an older adult,
including unfamiliar settings, acute distress, infection, dehydration, and hypoxia; however, most of these
issues are unlikely to be quickly or easily resolved. Residual effects of a stroke can also impair the client's
ability to interact with the environment, but this client's aphasia is an input rather than a reception
impairment with regard to interaction with the environment.
12) A
- After spinal surgery, financial and work-related concerns are managed by a social worker whose role is
to assist the client with health carerelated social issues by making use of community agencies and
resources. A physical therapist has the best knowledge of techniques for increasing mobility, endurance,
flexibility, and strength. The clinical nurse specialist and the neurosurgeon are specialists who are
important in the physical care of the neurosurgical client and who can make the referral to the social
worker.
13) C
- In the Cuban-American culture, loud crying and other physical manifestations of grief are acceptable.
The nurse provides culturally sensitive care and a caring approach to the client and family by providing a
private room for grieving while still fulfilling the duty owed to the other clients. The nurse can direct the
family to the chapel upon their request. Closing the doors to other clients' rooms can increase the risk of
client injury and annoyance. Asking the grieving family to be considerate can be misinterpreted as being
disrespectful to their culture.
14) C
- The client is experiencing loss from two life-changing experiences: her poor prognosis and the loss of
control over the environment, independence, and privacy that accompanies admission to a long-term care

facility. To meet the client's psychosocial needs, the nurse promotes a therapeutic relationship and allows
the client to verbalize her feelings. Options A and D help to manage physical needs. Although total care
may be necessary, it does not necessarily facilitate a therapeutic relationship. Providing pain medication
is indicated as part of effective pain management; however, this can interfere with therapeutic
communication if the client is too sedated. Engaging the client in social activities is unlikely to effectively
meet the client's psychosocial needs relating to loss; it is more likely to help diminish loneliness and
isolation.
15) B
- Anger is a stage in the grieving process and an expected response to impending loss. Usually a client
directs the anger toward him- or herself, God or another spiritual being, or the caregivers; thus far the
client's behavior demonstrates effective coping. Analyzing previous health care and alternative treatment
options is likely to interfere with effective coping, and it can delay lifesaving treatment. Notifying the risk
management department is premature, especially since the client has said nothing about legal action.
16) D
- Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may
exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes.
Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of
red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those
cells were instrumental in fighting infection in the body.
- Test-Taking Strategy: Use knowledge regarding the potential uses and benefits of the various types of
blood product transfusions. Eliminate increased hematocrit and increased hemoglobin first because they
are comparable or alike . From the remaining options, recalling that platelets are necessary for proper
blood clotting will direct you to the correct option.
17) A
- Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion
reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the
first 15 minutes. The other options do not identify assessments that are a priority just before beginning a
transfusion.
- Test-Taking Strategy: Note the strategic word priority. This tells you that more than one of the options
may be partially or totally correct and that the correct option needs to be assessed for possible
comparison during the transfusion. Use the ABCsairway , breathing , and circulation to direct you
18) B
- Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is
usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene
quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients
during this time. Therefore, the remaining options are incorrect time frames.
- Test-Taking Strategy: Focus on the subject , monitoring a client receiving a blood transfusion, and use
knowledge regarding blood transfusion procedures to answer this question. Remember that the client
must be monitored directly for the first 15 minutes of the transfusion.
19) B
- Rationale: New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion
are evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a
high-Fowlers (upright) position will facilitate breathing. Measures that increase blood return to the heart,
such as leg elevation and administration of intravenous fluids, should be avoided at this time. In addition,

administration of fluids cannot be initiated without a prescription. Consulting

with the health care provider regarding administration of oxygen may be necessary, but positional
changes take a short amount of time to do and should be initiated first.
- Test-Taking Strategy: Note the strategic word first . Apply knowledge of signs and symptoms of
circulatory overload and use the ABCsairway, breathing, and circulation to assist you with selecting the
priority action. Remember that placing the client in a high-Fowlers (upright) position will facilitate
breathing. Review: Signs of circulatory overload and associated nursing actions Level of Cognitive
20) D
- Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or white blood
cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse
notes the results of follow-up white blood cell counts and differential to evaluate the effectiveness of the
therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte
count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.
- Test-Taking Strategy: Note the strategic word effectiveness . Recalling that granulocytes are a
component of white blood cells will assist in directing you to the correct option. In addition, note that the
remaining options are comparable or alike in that these options all refer to red blood cells.