A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

"It must be very difficult for you to see your wife in pain."

"I wish there was more that I could do to relieve your wife's pain, too."

"I'm sure your wife will begin to feel better soon."

"We're doing everything we can to keep your wife comfortable."

Answer and Explanation

The Correct Answer is A

Answer: A

Rationale:

A) "It must be very difficult for you to see your wife in pain.": This response acknowledges the partner's feelings and provides emotional support. It shows empathy and validates the partner's experience, helping to build rapport and trust between the nurse and the family member.

B) "I wish there was more that I could do to relieve your wife's pain, too.": While this response expresses sympathy, it might unintentionally convey a sense of helplessness or inadequacy on the part of the nurse, which could increase the partner's anxiety or frustration.

C) "I'm sure your wife will begin to feel better soon.": This response is intended to be reassuring, but it can come off as dismissive of the partner's current concern and may not address their immediate emotional needs. It also makes a promise that the nurse cannot guarantee.

D) "We're doing everything we can to keep your wife comfortable.": This response provides factual information about the care being provided, but it does not address the partner's emotional distress. It focuses on the actions of the healthcare team rather than acknowledging the partner's feelings.

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Correct Answer is A

Explanation

The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.

Choice B, "Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.

Choice C, "Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.

Choice D, "I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.

A. Initiate one-to-one nursing observation. B. Make a contract with the client for weight gain. C. Administer the Hamilton depression scale. D. Review the client's toxicology laboratory report.

Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

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A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

Nursing Test Bank

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