A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?
"That's a hurtful thing to say."
"Tell me more about that."
"Well, that's your opinion."
"Why would you say such a thing?".
The Correct Answer is B
Choice A rationale:
Focuses on the nurse's feelings rather than the client's needs. This response may make the client feel guilty or defensive, and it does not address the underlying cause of their anger or frustration.
Shuts down communication. Saying "That's a hurtful thing to say" can signal to the client that the nurse is not open to hearing their concerns, which can hinder the development of trust and rapport.
Fails to acknowledge the client's pain. The client is in a vulnerable position, experiencing both physical and emotional pain. This response does not recognize the validity of their experience, which can further alienate them.
Choice B rationale:
Invites the client to share their perspective. By saying "Tell me more about that," the nurse demonstrates a willingness to listen and understand the client's concerns. This can help to build trust and rapport, and it can provide valuable insights into the client's experience.
Promotes exploration of feelings. Allowing the client to express their feelings can help them to process their emotions and to feel more understood. This can lead to a greater sense of control and empowerment, which can be beneficial for their overall coping and healing.
Gathers information to tailor care. By listening to the client's concerns, the nurse can gain a better understanding of their specific needs and preferences. This information can then be used to adjust the plan of care to better meet the client's individual needs.
Choice C rationale:
Dismisses the client's feelings. Saying "Well, that's your opinion" minimizes the client's experience and sends the message that their feelings are not important. This can damage the therapeutic relationship and make the client feel even more isolated and unsupported.
Fails to address the underlying issue. This response does not attempt to explore the reasons for the client's anger or frustration, which means that the problem is likely to continue.
Choice D rationale:
Sounds accusatory and confrontational. Asking "Why would you say such a thing?" can put the client on the defensive and make them feel like they have to justify their feelings. This can hinder open communication and make it more difficult to address the root of the problem.
May make the client feel judged or criticized. This response can come across as judgmental and uncaring, which can further alienate the client and damage the therapeutic relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: The client’s magnesium level is 1.7 mg/dL, which is below the normal range of 1.8 to 2.4 mg/dL. Hypomagnesemia can cause neuromuscular irritability, muscle weakness, tremors, and even seizures or cardiac arrhythmias in severe cases.
It’s often associated with other electrolyte imbalances such as hypokalemia and hypocalcemia.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, malabsorption, or excessive losses from the gastrointestinal tract.
Choice B rationale: The client’s chloride level is 98 mmol/L, which falls within the normal range of 96 to 106 mmol/L. Chloride is an important electrolyte that helps maintain acid-base balance, fluid balance, and is a component of gastric juice as hydrochloric acid.
There’s no immediate concern regarding the client’s chloride level.
Choice C rationale: The client’s phosphate level is 2.5 mg/dL, which is below the normal range of 2.8 to 4.5 mg/dL. Hypophosphatemia can lead to muscle weakness, bone pain, mental changes, and potentially life-threatening complications such as respiratory failure and heart failure.
In the context of anorexia nervosa, hypophosphatemia is a common complication during refeeding due to shifts in electrolytes.
Choice D rationale: The client’s potassium level is 3.5 mmol/L, which is at the lower end of the normal range of 3.5 to
5.0 mmol/L. Hypokalemia can cause muscle weakness, cramps, arrhythmias, and in severe cases, it can be life- threatening.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, excessive losses due to vomiting or laxative abuse, or shifts in electrolytes during refeeding.
In conclusion, the nurse should follow up on the client’s magnesium, phosphate, and potassium levels due to their potential implications on the client’s health, especially considering the client’s current health status and the process of refeeding.
Correct Answer is B
Explanation
While the client's statement might seem like other defense mechanisms, here's why Denial is the most fitting choice: Denial:
Involves refusing to acknowledge a painful or threatening reality.
The client attributes their cough, a potential symptom of lung cancer, to a common cold, dismissing the possibility of their condition worsening.
This allows them to avoid the emotional distress associated with facing their illness. Other options and their rationales:
Reaction formation (Choice A): This involves expressing the opposite of what one truly feels or desires. The client doesn't show any outward signs of expressing emotions opposite to their actual feelings about their health.
Suppression (Choice C): This involves consciously pushing unpleasant thoughts or feelings out of awareness. While the client might downplay the cough, they haven't completely pushed the thought of their illness away.
Regression (Choice D): This involves reverting to an earlier stage of development in response to stress. There's no indication of the client displaying behaviors characteristic of an earlier developmental stage.
Addressing other potential mechanisms:
Displacement: Redirecting emotions towards a less threatening target is not evident in the scenario.
Rationalization: Justifying behavior in a way that avoids facing the true reasons is not seen in the client's explanation. Projection: Attributing one's own feelings or desires to others is not present in the client's statement.
Remember:
Denial is a common coping mechanism for dealing with difficult realities like illness.
It's crucial for the nurse to assess the extent of the client's denial and offer support without judgment.
The goal is to help the client acknowledge their illness while providing emotional support and resources for managing their condition.
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