A client expresses fear about their upcoming diagnostic test What is the best response from the nurse?
Reflect on their statement and encourage further discussion
Change the subject to distract the client from their fear
Reassure the client that there is nothing to worry about
Provide detailed medical information about the diagnostic procedure
The Correct Answer is A
Choice A reason: Reflection is a therapeutic communication technique that involves redirecting the client's feelings back to them. By acknowledging the expressed fear, the nurse validates the client's emotional experience and creates an open, non-judgmental space for the client to elaborate on specific concerns. This allows the nurse to identify the root cause of the anxiety and provide targeted support.
Choice B reason: Changing the subject is a non-therapeutic technique known as introducing an unrelated topic. This dismisses the client’s valid concerns and may make them feel that the nurse is uncomfortable with their emotions or is too busy to listen. It effectively shuts down communication and prevents the nurse from addressing potential psychological barriers to the client's care.
Choice C reason: Providing false reassurance by telling a client "there is nothing to worry about" is patronizing and dismissive. It minimizes the client's feelings and can damage the therapeutic relationship by breaking trust. It also discourages the client from expressing further concerns, as they may feel their natural anxiety is irrational or unwelcome in the clinical setting.
Choice D reason: While patient education is important, providing cold, detailed medical information while a client is in an acute state of fear is often ineffective. High levels of anxiety interfere with cognitive processing and the ability to retain complex information. The nurse must first address the emotional distress before the client can effectively engage with technical details about the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring verbal responses to orientation questions regarding person, place, time, and situation is the primary clinical method for assessing the contents of consciousness. This technique evaluates the integration of cognitive functions and the ability of the cerebral cortex to process and articulate complex information, providing a clear metric for the level of awareness.
Choice B reason: Assessing gait while walking primarily evaluates cerebellar function, motor coordination, and musculoskeletal integrity rather than the level of consciousness. While a semi-conscious patient may have an altered gait, many patients with significantly impaired levels of consciousness are completely unable to ambulate, making this an inappropriate and potentially dangerous assessment tool for cognitive status.
Choice C reason: Asking a patient to shake hands is a simple command that tests the ability to follow instructions and motor response, but it does not provide a comprehensive view of orientation. A patient may perform this as a reflexive social gesture even while experiencing significant disorientation or delirium, thus failing to accurately gauge the depth of conscious awareness.
Choice D reason: Observing facial expressions provides subjective data regarding emotional state or pain levels but lacks the specificity required to determine a patient's level of consciousness. Facial symmetry or grimacing can occur in various states of altered consciousness or even in unconscious patients as a reflexive response to stimuli, making it an unreliable indicator of cognitive orientation.
Correct Answer is B
Explanation
Choice A reason: Using unauthorized internet translating services is a violation of hospital policy and patient privacy (HIPAA). These services are often inaccurate regarding complex medical terminology, which can lead to dangerous misunderstandings of the patient’s medical history, allergies, or current symptoms, potentially resulting in medical errors.
Choice B reason: Utilizing a facility-designated medical interpreter is the professional and legal standard for ensuring accurate communication. These professionals are trained in medical terminology and the ethics of confidentiality. This ensures that the patient fully understands their care plan and that the nurse receives precise subjective data for the admission assessment.
Choice C reason: Asking a family member or partner to interpret is non-therapeutic and ethically problematic. Family members may omit sensitive information, add their own biases, or fail to understand medical jargon. Furthermore, it places an inappropriate emotional burden on the family member and may violate the patient's right to private communication with their healthcare team.
Choice D reason: Relying on a bilingual colleague is generally discouraged unless they are formally certified as a medical interpreter. Using a colleague can pull them away from their own patient care duties and does not guarantee the same level of linguistic accuracy or adherence to interpreting standards that a professional facility-designated interpreter provides.
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