A nurse finds a client who is awaiting the results of diagnostic tests sitting in bed crying. Which response by the nurse would best facilitate communication?
“Would you like me to get you some tissues?”.
“I see that you’re upset. I’ll come back later.”.
“I see that you’re crying. Tell me about it.”.
“How can I help you?”.
The Correct Answer is C
Tell me about it.” This response by the nurse would best facilitate communication because it acknowledges the client’s emotional state and invites the client to express their feelings.
It also shows empathy and respect for the client.
Choice A is wrong because it does not address the client’s emotional needs or encourage communication.
It also implies that the nurse is uncomfortable with the client’s crying and wants to avoid it. Choice B is wrong because it does not show empathy or support for the client.
It also indicates that the nurse is too busy or unwilling to listen to the client.
Choice D is wrong because it is too vague and does not acknowledge the client’s emotional state.
It also puts the burden on the client to come up with a solution for their problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.
The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.
Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.
Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.
Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.
Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.
Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.
Beta-blockers can lower blood pressure, heart rate, and cardiac output.
They are not indicated for hypovolemia and can worsen the client’s condition.
To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.
For example: “I am (name), the nurse caring for (client name) in room (number).
I am calling because I am concerned that the client has developed hypovolemia after surgery.”
Background: Provide relevant and brief information related to the situation.
For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.
Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”
Assessment: Share your analysis and considerations of options. For
Correct Answer is B
Explanation
This outcome indicates that the client has resolved their constipation and has a regular pattern of defecation without difficulty or discomfort.
Choice A is wrong because taking a laxative daily can worsen constipation by causing dependency and reducing the natural peristalsis of the colon.
Choice C is wrong because requesting a bedpan every four hours does not necessarily mean that the client has bowel movements. It may indicate that the client has difficulty passing stool or has a sensation of incomplete emptying.
Choice D is wrong because having a bowel movement within 72 hours is still considered constipation. Constipation is diagnosed when bowel movements are associated with at least two of the following symptoms, occurring in the past three months with an onset of symptoms of at least six months: Less than three spontaneous bowel movements per week, Lumpy or hard stools from at least 25% of bowel movements.
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