A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

"This unit has a policy against staff harassment."

"It is important to dress the right arm first."

"Dressing must be a frustrating experience for you."

"We will give you a class on dressing tomorrow."

Monitor the client's white blood cell count.

Answer and Explanation

The Correct Answer is C

A. "This unit has a policy against staff harassment."

This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.

B. "It is important to dress the right arm first."

This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.

C. "Dressing must be a frustrating experience for you."

This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.

D. "We will give you a class on dressing tomorrow."

This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.

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Correct Answer is B

Explanation

A. "I am sorry to disturb you at a difficult time. This can wait until later."

This response acknowledges the client's distress but does not actively engage with the client's emotions or offer support. It also suggests postponing the assessment, which may not be necessary if the client is willing to discuss their feelings.

B. “While touching the client's forearm, asks, 'Would you like to talk about it?'"

This response demonstrates empathy and offers the client an opportunity to express their feelings if they wish to do so. By gently touching the client's forearm and asking if they would like to talk, the nurse conveys support and openness to the client's emotional needs.

C. "This is a bad time. I can see you are upset. I can come back later."

While this response acknowledges the client's emotions and offers to return later, it may not be the most helpful approach. It assumes that the client does not want to engage in conversation at that moment without giving them the opportunity to express their preferences.

D. “Gives the client a hug and says, 'It is okay to cry when you are sad.'"

While offering physical comfort like a hug can be appropriate in some situations, it's important to respect the client's personal boundaries and preferences, especially if they are in distress. Additionally, some clients may not feel comfortable with physical touch from healthcare providers. This response also assumes the client's emotions without directly addressing their needs or offering them an opportunity to express themselves verbally.

A. Places food on the unaffected side of the mouth. B. Raises the head of the bed to 60 degrees. C. Positions the head with the chin tilted slightly downward. D. Allows 30 minutes of rest before feeding.

Correct Answer is B

Explanation

A. Places food on the unaffected side of the mouth:

This is correct practice for clients at risk for aspiration. Placing food on the unaffected side helps ensure safer swallowing.

B. Raises the head of the bed to 60 degrees:

Clients at risk for aspiration-especially after a CVA (stroke)-should have the head of the bed elevated to at least90 degrees during feeding.60 degrees is insufficient to fully protect the airway and reduce the risk of aspiration.

C. Positions the head with the chin tilted slightly downward:

Positioning the head with the chin tilted slightly downward (chin tuck) helps close off the airway during swallowing, further reducing the risk of aspiration. This is another appropriate technique to minimize the risk of aspiration during feeding.

D. Allows 30 minutes of rest before feeding:

Resting reduces fatigue, which can improve swallowing safety and coordination.

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A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

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