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 B
Explanation
Choice A reason: Focusing only on the parents marginalizes the child and prevents the nurse from assessing the child's cognitive development, speech patterns, and emotional state. While parents are essential historians for pediatric cases, the child should be the primary focus of the assessment whenever developmental levels allow for direct interaction.
Choice B reason: Using open-ended questions directed at the child encourages them to express themselves in their own words, which is vital for building rapport. This strategy helps the nurse assess the child's level of orientation and maturity. It also signals to both the child and parents that the child's perspective is a valued part of the clinical process.
Choice C reason: Providing information on pediatric care is a form of patient education but does not address the immediate communication barrier. Education should follow the assessment phase. If the nurse focuses on providing information too early, they may miss critical subjective data that only a direct interaction with the child could provide.
Choice D reason: Using closed-ended questions with the parents further excludes the child from the conversation. While closed-ended questions are useful for specific data points (like date of birth), they do not facilitate the kind of expansive, expressive communication needed to understand a child's unique health experience or psychosocial needs.
Correct Answer is B
Explanation
Choice A reason: A client receiving enteral feeding has a nutritional risk factor, but their ability to change positions independently significantly mitigates the risk of prolonged tissue ischemia. Mobility is a primary protective factor in the Braden Scale, as it allows for the natural redistribution of pressure over bony prominences, preventing capillary occlusion.
Choice B reason: An unresponsive client who only changes position occasionally is at the highest risk due to the combination of impaired sensory perception and physical immobility. Being unresponsive means they cannot feel or react to the pain associated with tissue hypoxia, leading to prolonged pressure that exceeds capillary closing pressure, which rapidly causes cellular necrosis.
Choice C reason: A client who makes frequent changes in position and is ambulatory is at the lowest risk among the group. Active movement and walking maintain adequate peripheral circulation and ensure that no single area of skin is subjected to the sustained pressure required for the formation of stage 1 or deeper pressure injuries.
Choice D reason: While poor nutritional intake (eating only 25% of meals) is a recognized risk factor for skin breakdown, being alert and responsive allows the client to shift their weight in response to discomfort. Sensory perception and the ability to move independently are more significant predictors of immediate pressure injury risk than isolated nutritional deficits in an alert patient.
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