A client diagnosed with end-stage renal disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
"Perhaps you should discuss this with your physician."
"Of course, you aren't going to die, at least not in the immediate future."
"Tell me more about these fears of dying from a heart attack."
"I recommend you exercise daily and avoid smoking to decrease your risk."
The Correct Answer is C
Choice A Reason:
While suggesting the client discuss their concerns with their physician is a valid response, it may not provide the immediate emotional support the client is seeking. It's important for the nurse to address the client's current anxiety and provide reassurance before referring them to their physician.
Choice B Reason:
This response dismisses the client's fears and may come across as insensitive. It's crucial to acknowledge the client's emotions and provide a supportive environment where they feel heard and understood.
Choice C Reason:
Encouraging the client to express their fears allows the nurse to provide emotional support and helps in understanding the client's perspective. This approach fosters a therapeutic relationship and can help alleviate the client's anxiety.
Choice D Reason:
While recommending lifestyle changes is beneficial for overall health, this response does not address the client's immediate emotional needs. The nurse should first provide support for the client's expressed fears before discussing lifestyle modifications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Evaluation is the final step in the nursing process, where the nurse determines the effectiveness of the nursing care plan and whether the client's goals and outcomes have been met. In the context of milieu therapy, evaluation would involve assessing the client's progress within the therapeutic environment.
Choice B reason:
Planning involves setting goals and expected outcomes for the client's care and then determining the specific interventions that will be used to achieve those goals. In milieu therapy, planning would include designing the structure and activities of the therapeutic environment to meet the needs of the clients.
Choice C reason:
Assessment is the first step in the nursing process, where the nurse collects comprehensive data pertinent to the client's health and the situation. In milieu therapy, assessment would include understanding the client's mental health status, personal history, and specific needs within the therapeutic environment.
Choice D reason:
Implementation is the step where the nurse puts the care plan into action. In the context of milieu therapy, implementation refers to the nurse's role in actively creating and maintaining the therapeutic environment, facilitating group activities, and ensuring that the daily routine is therapeutic for all clients.
Correct Answer is C
Explanation
Choice A Reason:
A client exhibiting psychotic behavior may not be the best candidate for group therapy initially, as they might be experiencing delusions, hallucinations, or disorganized thinking that could disrupt the group process and might not be able to participate effectively. Individual therapy might be more appropriate until the client's symptoms are better managed.
Choice B Reason:
A client who was admitted 5 hours ago for acute mania is likely still experiencing heightened levels of energy, impulsivity, and possibly erratic behavior. They may not be able to engage in group therapy effectively and could benefit from stabilization before participating in a group setting.
Choice C Reason:
A client who has been taking lithium for 2 weeks for depression is likely to have achieved some level of stabilization of their mood. Lithium is a mood stabilizer used to treat bipolar disorder and depression, and after 2 weeks, the client may be ready to engage with others in a therapeutic group setting.
Choice D Reason:
A client who is in a manic state, similar to the client in choice B, may not be suitable for group therapy due to potential disruptive behavior and difficulty focusing on the group process. It's important for the client to receive individual attention to manage the mania before joining group therapy.
Question 43
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