A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

The reduced muscle tone relaxed the low muscles

"That happens when a person gets close to death

"I can apply a chin strap to help hold the mouth closed

Answer and Explanation

The Correct Answer is A

A. The reduced muscle tone had relaxed the law muscles CORRECT
Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.

B. "That happens when a person gets close to death INCORRECT
This automatic response is nontherapeutic and does not address the family member's question

C. "I can apply a chin strap to help hold the mouth closed INCORRECT
Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.

A. "Why are you angry about taking insulin?" B. "Don't worry. Diabetes runs in my family as well." C. "I see that you are angry. Let's sit down and talk." D. "You should take insulin because it reduces the risk for complications."

Correct Answer is C

Explanation

A: Asking the client why they are angry may come across as confrontational and defensive, potentially escalating the situation. It does not promote open communication or therapeutic rapport.
B: Sharing personal information about diabetes running in the nurse's family is not relevant to the client's feelings or concerns and may not be helpful in addressing the client's anger.
C: Correct. Acknowledging the client's feelings of anger and offering to sit down and talk provides an opportunity for therapeutic communication. This response demonstrates empathy and a willingness to listen and address the client's concerns about insulin therapy.
D: While it is true that insulin therapy can help reduce the risk of complications in type 2 diabetes, this response may come across as dismissive of the client's feelings and concerns. It does not address the emotional aspect of the client's anger.

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A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Exhibits Complete the following sentence by using the lists of options. Exhibit 1 The client has manifestations of an dropdown as evidenced by the client's dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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