A nurse is caring for a client who is about to undergo open-heart surgery. The client states that he is very nervous about the surgery. Which of the following responses should the nurse make?

Give the client some reading material about their upcoming surgery to help ease their mind.

Suggest that the client take a walk around the unit.

Refer the client to the pastoral care team.

Speak with the client and ask him to describe what they are feeling.

Answer and Explanation

The Correct Answer is D

Choice A reason:
Providing reading material about the surgery can be informative, but it may not be the best approach for someone who is already very nervous. It could potentially increase anxiety if the information is overwhelming or if the client misinterprets the material.

Choice B reason:
Suggesting a walk could serve as a distraction and help to calm the client's nerves. However, it might not address the underlying anxiety about the surgery itself. It's a temporary measure that doesn't offer emotional support or address the client's immediate concerns.

Choice C reason:
Referring the client to the pastoral care team could be beneficial if the client is seeking spiritual support or comfort. However, this should be based on the client's personal preferences and beliefs, and it may not be the most direct way to address the client's stated nervousness.

Choice D reason:
Engaging the client in a conversation about their feelings provides an opportunity for emotional support and can help the nurse understand the client's specific fears. This approach can lead to a more personalized care plan to alleviate anxiety.

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Correct Answer is A

Explanation

Choice A reason:
Talking directly to the client and setting clear boundaries is a therapeutic approach. It respects the client's autonomy while also addressing the behavior that is affecting the therapeutic environment. By identifying specific limits, the nurse helps the client understand the consequences of their actions and the importance of maintaining a respectful and honest communication with others.

Choice B reason:
Discussing the problem in a community meeting could be helpful, but it should not be the initial action. This approach might inadvertently shame or embarrass the client in front of peers, which could exacerbate the situation. It's important to address the behavior privately before involving the larger group.

Choice C reason:
Escorting the client to their room each time they socialize could be seen as punitive and may not address the underlying reasons for the lying behavior. It could also isolate the client from social interactions that are an essential part of the healing process.

A. Adventitious B. Maturational C. Developmental D. Situational

Correct Answer is D

Explanation

Choice A Reason:
An adventitious crisis is not applicable here. This type of crisis is usually a result of a natural or man-made disaster, war, or major accident, which is not the case with the client's situation.

Choice B Reason:
Maturational crises are associated with life transitions or developmental stages, such as retirement or menopause. While the client is older, the crisis is not due to a normal life transition but rather an unexpected event.

Choice C Reason:
Developmental crises occur as a person moves through the stages of life. The client's crisis does not stem from a developmental issue but from an external event that has disrupted their life.

Choice D Reason:
Situational crises arise from external sources that an individual may face throughout life, such as the death of a loved one, loss of a job, or severe illness. The client's inability to cope with the sudden death of their spouse is a situational crisis.

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A nurse is caring for a client who is about to undergo open-heart surgery. The client states that he is very nervous about the surgery. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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