A client's father has recently died. Which response from the nurse would be most therapeutic?

‘I know how you feel. I've lost people close to me too."

"Your mother is still living to give you support."

"You will never be the same. This will make you stronger"

1 am sad for you. I'll stay with you for a while if you need to talk."

Answer and Explanation

The Correct Answer is D

D. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.

A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.

B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.

C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.

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Correct Answer is C

Explanation

C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.

A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.

B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.

D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.

A. activity intolerance. B. ineffective breathing pattern. C. ineffective gas exchange. D. ineffective airway clearance.

Correct Answer is D

Explanation

D. This refers to the inability to clear secretions or obstructions from the respiratory tract to maintain airway patency. Based on the client's complaint of difficulty moving mucus from the throat to the mouth for expectoration, ineffective airway clearance is the priority problem. The client's reluctance to cough and deep breathe due to pain further exacerbates this issue, as effective airway clearance is crucial for preventing complications such as respiratory infections or atelectasis post-operatively.

A. Activity intolerance refers to insufficient physiological or psychological energy to endure or complete required or desired daily activities. In the case of a one-day post-operative client experiencing difficulty clearing mucus, activity intolerance is not the priority problem. The client's main issue is related to respiratory function and airway clearance rather than overall activity tolerance.

B. This refers to abnormal respiratory rate, depth, or rhythm that does not provide adequate ventilation. While the client's complaint of difficulty moving mucus and reluctance to cough or deep breathe suggests some respiratory discomfort, the main issue appears to be the inability to effectively clear airway secretions rather than an overall ineffective breathing pattern.

C. This refers to the inability to exchange oxygen and carbon dioxide across the alveolar-capillary membranes. While mucus in the throat can potentially affect gas exchange if it obstructs airflow significantly, the client's primary complaint is about difficulty clearing mucus rather than signs and symptoms of inadequate oxygenation or ventilation.

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A client's father has recently died. Which response from the nurse would be most therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)