A client says to a nurse, “I’m afraid of radiation therapy.” The nurse replies, “Radiation kills the cancer cells.” Which statement best describes the nurse?
She is able to confront a painful subject.
She needs to learn more from the client.
She recognizes that the client needs information.
She perceives that the client is ready to hear more about the treatment.
The Correct Answer is B
This is because the nurse’s reply does not address the client’s fear of radiation therapy, but rather provides factual information that may not be relevant or helpful to the client.
The nurse is not using a therapeutic communication technique, such as reflecting, exploring, or validating the client’s feelings.
Instead, the nurse is shutting down the communication and missing an opportunity to learn more about the client’s concerns and needs.
Choice A is wrong because the nurse is not confronting a painful subject, but rather avoiding it.
The nurse is not acknowledging the client’s fear or inviting the client to talk more about it.
Choice C is wrong because the nurse is not recognizing that the client needs information, but rather assuming that the client does.
The nurse is not asking the client what he or she wants to know about radiation therapy, but rather telling the client what he or she should know.
Choice D is wrong because the nurse is not perceiving that the client is ready to hear more about the treatment, but rather imposing information on the client.
The nurse is not assessing the client’s readiness to learn, but rather giving unsolicited advice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.
Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.
Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.
Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.
Correct Answer is D
Explanation
The client with a labored respiratory rate of 28 should be seen first because this indicates respiratory distress, which is a life-threatening condition that requires immediate intervention. Respiratory rate is one of the vital signs that are used to assess the severity of a patient’s condition and to triage them accordingly. A normal respiratory rate for an adult is 12 to 20 breaths per minute.
Choice A is wrong because a large laceration on the left scapula is not as urgent as respiratory distress.
A laceration is a wound that involves a cut or tear in the skin, which may cause bleeding, pain, and infection. However, it can be managed with wound care and suturing in the urgent care center.
Choice B is wrong because a compound fracture of the right tibia is not as urgent as respiratory distress.
A compound fracture is a fracture that breaks through the skin, which may cause bleeding, pain, infection, and nerve or blood vessel damage. However, it can be stabilized with splinting and dressing in the urgent care center before transferring to a hospital for further treatment.
Choice C is wrong because being unable to breastfeed a 4 week old is not as urgent as respiratory distress.
Breastfeeding difficulties may be caused by various factors, such as poor latch, low milk supply, sore nipples, or mastitis. However, they can be managed with education, support, and medication in the urgent care center.
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