A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take?

Ask him what is making him cry.

Provide quiet times for these moments.

Contact the hospital's spiritual services.

Turn on the television for a distraction.

Answer and Explanation

The Correct Answer is B

Rationale:

A. While showing interest in a client’s feelings can be supportive, directly questioning may interrupt a reflective or spiritual moment and could make the client feel pressured to explain or justify their emotions. It may distract from their personal coping process.

B. Allowing the client privacy and quiet time respects their emotional and spiritual needs. This intervention supports self-expression and processing of grief, joy, or spiritual reflection without imposing external expectations. Nurses facilitate a healing environment by recognizing when clients need solitude for reflection or prayer.

C. Involving spiritual services may be helpful if the client requests support, but doing so without the client’s consent could infringe on their autonomy. The immediate priority is to respect the client’s current emotional and spiritual moment.

D. Using distraction disregards the client’s need for emotional expression and spiritual reflection. This approach invalidates the client’s experience and may increase feelings of isolation or frustration.

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Correct Answer is C

Explanation

Rationale:

A. Inserting a Foley catheter is a sterile, invasive procedure that requires licensure and specific training. This task is beyond the scope of practice for a CNA, as it involves risk of infection and requires clinical judgment.

B. Assessing pain is a nursing judgment task that requires evaluating subjective and objective data, analyzing trends, and possibly adjusting interventions. CNAs can report observations (e.g., facial expressions, vital signs) but cannot determine or document pain levels independently.

C. CNAs are trained to assist clients with basic activities of daily living (ADLs) and mobility, including ambulating patients safely. They can support the nurse by helping clients move, preventing falls, and encouraging physical activity, under the supervision of licensed nurses.

D. Client education involves assessment, clinical judgment, and teaching about disease management, medications, and lifestyle modifications. This is a nursing responsibility, not within the CNA scope of practice. CNAs can reinforce prior teaching but cannot independently provide disease-specific education.

A. "I think you would feel better if you talked about your feelings with a support group." B. "Do other members of your family also feel this way?" C. "You sound angry. Anger is a normal feeling associated with loss." D. "I understand just how you feel. I felt the same when my guardian died."

Correct Answer is C

Explanation

Rationale:

A. This response minimizes the client’s current feelings and redirects them without first acknowledging or validating the emotion. While support groups are helpful, immediately suggesting them may make the client feel dismissed or unheard.

B. This response shifts focus to others rather than addressing the client’s personal feelings. At this stage of grief, the client needs validation and emotional support, not comparison with family members.

C. This response demonstrates therapeutic communication by acknowledging and validating the client’s feelings. Labeling the emotion as anger normalizes the reaction, helps the client feel understood, and encourages further expression. It supports the grieving process by recognizing emotions as part of normal bereavement.

D. This response is non-therapeutic because it shifts the focus to the nurse’s personal experience rather than the client’s feelings. It can unintentionally minimize the client’s unique grief and may make the client feel that their emotions are less important.

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A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take?

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