A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?
"I am sure these feelings will pass once you go home."
"Tell me what you understand about your illness."
"Tell me why you feel hopeless."
"If I were you, I would ask for a referral to hospice care."
The Correct Answer is B
Rationale:
A. "I am sure these feelings will pass once you go home." is dismissive and does not address the client's current emotional state.
B. "Tell me what you understand about your illness." opens up a dialogue for the client to express their feelings and concerns, which can help in assessing their emotional state and providing support.
C. "Tell me why you feel hopeless." might be too direct and could make the client feel pressured.
D. "If I were you, I would ask for a referral to hospice care." could be perceived as judgmental and does not address the client’s immediate feelings of hopelessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. WBC 6,000/mm³ is within normal range and does not require follow-up.
B. BUN 15 mg/dL is within normal range and does not require follow-up.
C. Hemoglobin 14 g/dL is within normal range for most adults and does not require follow-up.
D. Platelet count 60,000/mm³ is significantly low and requires follow-up as it can increase the risk of bleeding during surgery.
Correct Answer is C
Explanation
A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.
B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.
C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.
D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.
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