A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?
It must be hard to see your mother so ill and upset.
If you just sit quietly with your mother, I'm sure she will calm down.
I'll talk with your mother and see if I can comfort her.
"Your mother's crying seems to bother you more than it does her."
The Correct Answer is A
A. It must be hard to see your mother so ill and upset is a compassionate and empathetic response that acknowledges the son's distress while validating his feelings. This approach fosters open communication and emotional support, which is important for both the patient and their family.
B. Telling the son to sit quietly with his mother may invalidate his feelings and suggests that the solution is simply to wait for the mother to calm down. It does not acknowledge his emotional distress or provide the necessary support.
C. While offering to comfort the mother is kind, this response does not address the son’s emotional needs. It is important to support the family members as well, not just the patient.
D. "Your mother's crying seems to bother you more than it does her" is dismissive of the son's feelings and could make him feel misunderstood or judged. It does not provide the necessary emotional support for the son.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Educating the client on anticonvulsant medications is important, but it is not the priority during an active seizure. Education should be provided after the seizure has ended.
B. Monitoring vital signs is important but should not be the immediate priority during a seizure. The nurse should focus on airway management first.
C. Restraining the client is contraindicated during a seizure. Restraining can cause injury to both the client and the nurse. The focus should be on protecting the client from harm.
D. The prevention of occlusion of the airway or aspiration is the priority. During a tonic-clonic seizure, there is a risk of the client choking, biting their tongue, or having difficulty breathing. The nurse should ensure the airway is open, prevent aspiration, and protect the client from injury during the seizure.
Correct Answer is D
Explanation
A. A positive Romberg sign (difficulty maintaining balance with eyes closed) can indicate a neurological issue, but it is not directly associated with a migraine.
B. A subnormal temperature (low body temperature) is not typically associated with migraines and may indicate another issue, but it is not as concerning as other findings.
C. An ill college roommate might suggest a viral illness, but it is not a direct concern for the student’s migraine. Migraines are not contagious, and other signs of illness would be more concerning.
D. Positive Brudzinski sign, which involves involuntary flexion of the hips and knees when the neck is flexed, is indicative of meningeal irritation, a sign of meningitis. This is a medical emergency and much more concerning than the symptoms of a migraine. The student should be further assessed for signs of meningitis, which requires urgent treatment.
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