A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?
"I suggest that you get control of yourself”
"Please stop yelling. I brought dinner as soon as I could”
"Do you need something for pain right now?"
"You seem upset. I have time to talk if you'd like”
The Correct Answer is D
A. "I suggest that you get control of yourself": This response is judgmental and dismissive of the client's feelings. It does not acknowledge the client's emotional state or offer a supportive approach to address their anger.
B. "Please stop yelling. I brought dinner as soon as I could": This response focuses on justifying the nurse's actions and does not acknowledge the client's emotional needs. It also shuts down the conversation by demanding the client stop yelling, rather than addressing their feelings.
C. "Do you need something for pain right now?": While the client may need pain management, this response doesn't address the client's anger which might be related to stress or frustration. It overlooks the opportunity to understand the root cause of the outburst.
D. "You seem upset. I have time to talk if you'd like.": This response is empathetic and non-confrontational. It acknowledges the client's emotional state and offers a space for them to express their feelings. It shows willingness to listen, which can help de-escalate the situation and provide emotional support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Test the drainage for glucose: Clear drainage from the nose following a basal skull fracture may be cerebrospinal fluid (CSF). The nurse should first test the drainage for glucose, as CSF contains glucose, which can confirm the presence of CSF.
B. Ask the client to blow his nose: Asking the client to blow their nose could increase the pressure in the skull and worsen the leakage of CSF, potentially causing more harm. This should be avoided in this situation.
C. Suction the nostril: Suctioning the nostril could increase the risk of further injury to the skull or brain, especially if CSF is leaking. The focus should be on confirming the presence of CSF, not suctioning the nostril.
D. Notify the physician: While notifying the physician is important, confirming whether the drainage is CSF first will guide the physician in making a more informed decision. Testing for glucose is the immediate action to confirm whether the fluid is CSF.
Correct Answer is B
Explanation
A. The client was last suctioned 6 hours ago: Time alone doesn’t indicate the need for suctioning. Suctioning is performed based on assessment findings, not routine schedules.
B. The client's respiratory rate is 32 breaths/min: A rapid respiratory rate can signal airway obstruction, secretions, or respiratory distress—all of which may require suctioning to improve ventilation.
C. The client has occasional audible expiratory wheezes: Wheezes suggest lower airway narrowing, which typically doesn’t improve with suctioning. Suctioning targets upper airway secretions, not bronchospasm.
D. The client's oxygen saturation drops to 95%: A saturation of 95% is still within normal limits and doesn't, by itself, suggest the need for suctioning unless accompanied by other signs like crackles, visible secretions, or distress.
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