A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
"Perhaps you should discuss this with your physician."
"Of course, you aren't going to die, at least not in the immediate future."
"I recommend you exercise daily and avoid smoking to decrease your risk."
"Tell me more about these fears of dying from a heart attack.".
The Correct Answer is D
Choice A rationale:
Deflecting the client's concerns to the physician dismisses the client's immediate need for emotional support and therapeutic communication.
It can hinder the development of a trusting nurse-client relationship.
The nurse is responsible for addressing the client's psychosocial needs, not solely deferring them to other healthcare professionals.
Choice B rationale:
Offering false reassurance is inappropriate and potentially harmful. It can erode trust if the client's fears are later realized.
It minimizes the client's legitimate concerns and invalidates their emotional experience.
Choice C rationale:
While lifestyle modifications are essential for managing coronary artery disease, providing unsolicited advice at this moment disregards the client's emotional distress.
It prioritizes physical health over the client's psychological well-being. It can be perceived as dismissive of the client's fears and concerns.
Choice D rationale:
Inviting the client to elaborate on their fears demonstrates active listening and encourages therapeutic communication. It validates the client's concerns and shows empathy for their emotional experience.
It provides an opportunity to assess the client's understanding of their condition and identify specific fears or misconceptions. It establishes a foundation for exploring coping mechanisms and providing appropriate support and education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","G"]
Explanation
The correct answer/s is Choice/s A, E, and G.
Choice A rationale: Administering 0.9% sodium chloride IV is a common practice in emergency departments to ensure the patient is well-hydrated. This is particularly important for patients experiencing acute mania, as they may have neglected their physical health, including hydration, during their manic episode.
Choice B rationale: Flumazenil is an antagonist for benzodiazepines and is typically used to reverse the sedative effects of benzodiazepines. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice C rationale: Preparing the client for intubation is usually reserved for situations where the patient is unable to maintain their own airway or adequate ventilation. This is not typically necessary in cases of acute mania unless there are other complicating factors.
Choice D rationale: Beginning chest compressions is a response to cardiac arrest. There is no indication in the that the patient is experiencing cardiac arrest, so this would not be a typical anticipation for a patient experiencing acute mania.
Choice E rationale: Administering IV naloxone is done in cases of suspected opioid overdose. While it’s not directly related to treating acute mania, it’s possible that the patient could have comorbid substance use issues, given the high rate of comorbidity between bipolar disorder and substance use disorders.
Choice F rationale: Administering activated charcoal is done in cases of certain types of poisoning or drug overdose. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice G rationale: Preparing the client for electroconvulsive therapy (ECT) could be an appropriate anticipation for a patient experiencing acute mania. ECT is considered a highly effective treatment for severe mania, particularly when other treatments have failed or when rapid stabilization is required.
Correct Answer is A
Explanation
Choice A rationale:
Supporting the client's wish to refuse prescribed medications directly aligns with the ethical principle of autonomy. Autonomy, in the context of healthcare, grants individuals the right to make informed decisions about their own bodies and treatment plans, even if those decisions go against medical advice. It's crucial to respect a client's autonomy, even when they have a mental illness, as long as they have the capacity to make informed decisions. Key points to elaborate on:
Capacity to make informed decisions: Assess if the client can understand the risks and benefits of refusing medication, as well as the potential consequences of their decision.
Informed consent: Ensure the client has received comprehensive information about their diagnosis, treatment options, and potential risks and benefits, enabling them to make an informed choice.
Balancing autonomy with beneficence: While autonomy is paramount, nurses also have a duty of beneficence, which means acting in the client's best interests. Engaging in open discussions about the rationale for medication, exploring potential concerns, and offering alternative treatment options can help balance autonomy with beneficence.
Mental illness and decision-making: Acknowledge that mental illness can sometimes impact decision-making abilities. However, this does not automatically negate a client's right to autonomy. Careful assessment and ongoing communication are essential.
Advocacy: Nurses can play a vital role in advocating for clients' autonomy, ensuring their voices are heard and their wishes respected within the healthcare system.
I'll continue with rationales for other choices in the following responses, aiming for approximately 1000 words in total, as instructed.
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