A nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of the following actions should the nurse take?
Ask the client to describe their feelings.
Discuss the competency of the surgeon with the client.
Inform the client that others have had the procedure without problems.
Ask the client why they are experiencing anxiety.
The Correct Answer is A
A. Ask the client to describe their feelings. Encouraging the client to express their emotions allows the nurse to assess their concerns and provide appropriate support. This is a key principle of therapeutic communication.
B. Discuss the competency of the surgeon with the client. While the surgeon's competency may help reassure the client, the nurse should not comment on the surgeon’s skill. Instead, the nurse should focus on the client's emotions and provide factual information about the procedure if needed.
C. Inform the client that others have had the procedure without problems. This response dismisses the client’s concerns rather than addressing their feelings. Each client’s experience is unique, and reassurance should be based on listening and providing accurate information.
D. Ask the client why they are experiencing anxiety. Asking “why” can make the client feel defensive. Instead, the nurse should use open-ended questions, such as "Can you tell me more about your concerns?", which encourages discussion without judgment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.
B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.
C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.
D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.
Correct Answer is B
Explanation
A. "I need to have an attorney sign my advance directives." An attorney is not required to sign an advance directive. The document typically requires the client’s signature and witnesses but does not need legal counsel unless state laws specify otherwise.
B. "I have a living will that outlines my wishes if I am unable to make decisions." A living will is a type of advance directive that specifies the client’s preferences for medical care if they become unable to make decisions. This statement shows understanding.
C. "I must have a family member appointed to make my health care decisions." While a client can appoint a family member as a healthcare proxy, it is not required. The client may choose any trusted individual to act as their healthcare power of attorney.
D. "I will need to sign a document stating that I want to be resuscitated if I require CPR." A Do Not Resuscitate (DNR) order is signed when a client chooses not to receive CPR. If the client wants resuscitation, no additional documentation is required—healthcare providers automatically provide life-saving measures unless a DNR order is in place.
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