A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of dying." Which of the following responses should the nurse make?
"I think you should call your friends to comfort you."
"Things are not as bad as they seem right now."
"It must be a very difficult time for you."
"Why are you afraid that you are going to die?"
The Correct Answer is C
A. "I think you should call your friends to comfort you.": This deflects the client’s feelings and shifts responsibility to others, rather than addressing the client’s immediate emotional needs.
B. "Things are not as bad as they seem right now.": This minimizes the client’s fear and invalidates their feelings, which can prevent open communication about their concerns.
C. "It must be a very difficult time for you.": This is a therapeutic, empathetic response that acknowledges the client’s emotions and encourages them to share their fears in a supportive manner.
D. "Why are you afraid that you are going to die?": Asking "why" can sound judgmental or probing, which may make the client defensive instead of fostering trust and open discussion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 15°: This angle is used for intradermal injections, such as a tuberculin skin test, where the medication is deposited just under the epidermis. It would not allow the needle to reach the muscle layer, making it inappropriate for intramuscular administration.
B. 60°: An angle of 60° is not a standard technique for any specific injection type. At this angle, the medication would likely end up in the subcutaneous tissue instead of the muscle, leading to improper absorption and reduced effectiveness.
C. 45°: This angle is appropriate for subcutaneous injections, such as insulin, when a shorter needle is used or in thin clients. It does not penetrate deeply enough to reach the muscle tissue for intramuscular medication administration.
D. 90°: A 90° angle ensures the needle penetrates through the subcutaneous tissue and into the muscle, which is necessary for intramuscular injections. This angle allows the medication to be deposited directly into the muscle for proper absorption and therapeutic effect.
Correct Answer is A
Explanation
A. Determine the source of the client's stress: The first step in managing insomnia related to stress is assessing and identifying the underlying cause. Understanding the source allows the nurse to tailor interventions effectively and ensures that care addresses the root of the problem rather than just the symptoms.
B. Instruct the client to turn off their TV just before they go to bed: Reducing screen time before sleep is helpful in promoting rest, but this is a specific behavioral strategy. It should follow an assessment of the client’s stressors and sleep patterns to be applied appropriately.
C. Encourage the client to listen to soft music at the onset of stress: Relaxation techniques such as music therapy can aid stress reduction, but they are supportive measures. Without assessing the client’s unique stressors first, these interventions may not fully address the insomnia.
D. Advise the client to exercise daily in the morning: Morning exercise can improve sleep quality and reduce stress, but it is a long-term strategy. The nurse must first explore the client’s stress triggers to ensure that interventions are individualized and effective.
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