A nurse is caring for a client who has a traumatic brain injury. The client says to the nurse, "I don't remember what happened to me." How should the nurse respond?
"You have a brain injury that affects your memory."
"Don't worry, your memory will come back soon."
"What do you think happened to you?"
"Tell me more about how you feel right now."
The Correct Answer is D
Choice A reason:
This is an incorrect answer. The nurse should not give information that might overwhelm or distress the client without assessing their readiness to learn.
Choice B reason:
This is an incorrect answer. The nurse should not give false reassurance or minimize the client's condition.
Choice C reason:
This is an incorrect answer. The nurse should not ask questions that might confuse or frustrate the client who has memory impairment.
Choice D reason:
This is a correct answer. The nurse should use therapeutic communication techniques such as exploring feelings, reflecting, and active listening to provide emotional support and establish rapport with the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
This is an incorrect answer. A tonic-clonic seizure (also known as a grand mal seizure) is characterized by alternating phases of muscle rigidity and jerking movements, along with loss of consciousness and postictal confusion.
Choice B reason:
This is a correct answer. An absence seizure (also known as a petit mal seizure) is characterized by brief episodes of staring, blinking, lip smacking, or other subtle movements, along with impaired awareness and no postictal confusion.
Choice C reason:
This is an incorrect answer. A myoclonic seizure is characterized by sudden, brief, and irregular muscle contractions, usually involving the arms, legs, or trunk.
Choice D reason:
This is an incorrect answer. An atonic seizure (also known as a drop attack) is characterized by sudden loss of muscle tone, resulting in falling or collapsing.
Correct Answer is A
Explanation
Choice A reason:
This is a correct answer. Elevating the head of the bed to 30 degrees helps to reduce ICP by facilitating venous drainage from the brain and decreasing cerebral edema.
Choice B reason:
This is an incorrect answer. Administering morphine sulfate for pain relief can increase ICP by causing vasodilation, respiratory depression, and increased carbon dioxide levels in the blood.
Choice C reason:
This is an incorrect answer. Encouraging coughing and deep breathing exercises can increase ICP by increasing intrathoracic pressure, which impedes venous drainage from the brain.
Choice D reason:
This is an incorrect answer. Performing passive range of motion exercises can increase ICP by stimulating the sympathetic nervous system, which increases blood pressure and cerebral blood flow.
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