A client who experienced a myocardial infarction tells the nurse that he is fearful of dying.
Which statement by the nurse will help validate this client's feelings?

"It must be very frightening to be told that you've had a heart attack.”.

"Why are you afraid? Can you explain your fear of dying?"

"Please be assured that we're doing everything possible to prevent you from dying.”.

"Facing death would certainly be a frightening experience for me.”.

Answer and Explanation

The Correct Answer is A

This scenario requires the application of therapeutic communication principles, specifically validation. Validating feelings involves acknowledging the client's emotional state without dismissing it. Nurses must distinguish between open-ended exploration, false reassurance, and self-disclosure to effectively support patients experiencing acute psychological distress.

Choice A rationale

Validation occurs when the nurse acknowledges the client's subjective experience. Myocardial infarction triggers significant anxiety regarding mortality. Acknowledging that the situation is frightening provides empathy and validates the client's feelings without being dismissive or providing false reassurance.

Choice B rationale

Asking why is often perceived as accusatory and may put the client on the defensive. It requires the client to analyze their emotions logically during a crisis, which can block further therapeutic communication and effective emotional expression.

Choice C rationale

This statement provides false reassurance. In a clinical setting, nurses cannot guarantee specific outcomes. This approach shuts down the client's expression of fear by shifting the focus to clinical actions rather than acknowledging the emotional reality.

Choice D rationale

This is an example of self-disclosure. By focusing on the nurse's own hypothetical feelings, the conversation shifts away from the client. Therapeutic communication must remain client-centered rather than focusing on the nurse's personal perspectives or reactions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["No"]

Explanation

The correct answer is No.

Step 1 is 14 lbs ÷ 2.2 lb/kg = 6.36363636 kg.

Step 2 is 6.36 kg × 20 mg/kg/day = 127.2 mg/day for the minimum safe dose.

Step 3 is 6.36 kg × 30 mg/kg/day = 190.8 mg/day for the maximum safe dose.

Step 4 is 35 mg × (24 hours ÷ 4 hours) = 35 mg × 6 doses = 210 mg/day for the total daily dose.

Step 5 is 210 mg/day > 190.8 mg/day, which exceeds the recommended maximum daily range.

A. Provide frequent oral and nares care. B. Encourage the client to consume clear liquids. C. Ambulate the client four times per day. D. Keep the client in a supine position.

Correct Answer is A

Explanation

Managing esophagogastric balloon tamponade requires knowledge of airway protection and mucosal integrity. Applying nursing interventions for a client with a Sengstaken-Blakemore tube involves preventing complications like aspiration and tissue necrosis while maintaining the mechanical pressure needed for hemostasis.

Choice A rationale

Frequent oral and nares care is essential because the tube causes irritation and prevents the client from swallowing saliva. Secretions accumulate in the upper airway, increasing infection risk and skin breakdown at the insertion site.

Choice B rationale

Clients with a Sengstaken-Blakemore tube must remain strictly NPO to prevent aspiration and avoid disturbing the tube. The balloon occupies the esophagus and stomach to stop variceal bleeding, making oral intake impossible and extremely dangerous.

Choice C rationale

Ambulation is contraindicated for a client with an active balloon tamponade due to the risk of tube displacement. Displacement can lead to airway obstruction if the gastric balloon migrates upward into the oropharynx or trachea.

Choice D rationale

A supine position increases the risk of aspiration and respiratory distress. The nurse should maintain the head of the bed at 30 to 45 degrees to facilitate breathing and minimize the risk of pulmonary complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client who experienced a myocardial infarction tells the nurse that he is fearful of dying. Which statement by the nurse will help validate this client's feelings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician prescribes ticarcillin 35 mg IV every 4 hours for a client post kidney transplant. The client weighs 14 lbs. The nursing drug reference recommends a maximum of 20-30 mg/kg/day. Is the ordered dose for this client safe? Yes or No.

Correct Answer is ["No"]

Explanation

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A client in the rehabilitative phase of a burn injury has healed graft sites and is beginning mobility exercises. Which intervention is most important to minimize scarring and promote functional recovery?

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?

A client with Amyotrophic Lateral Sclerosis (ALS) tells the hospice nurse they do not want to be intubated and placed on mechanical ventilation. How should the nurse best respond?

The trauma intensive care nurse suspects a client with a C6 fracture has developed neurogenic shock. Which findings support the nurse's suspicion?

The nurse provides discharge teaching to a client who had a myocardial infarction. Which statements by the client indicate an understanding? Select all that apply.

The intensive care nurse is caring for a client with sepsis. Which interventions can the nurse delegate to the unlicensed assistive personnel? Select All that Apply.

The nurse is delegating care for a client with a stroke who has dysphagia. Which task is appropriate to assign to the unlicensed assistive personnel (UAP)?

A client who experienced a myocardial infarction tells the nurse that he is fearful of dying.
Which statement by the nurse will help validate this client's feelings?