A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?
"How long have you struggled with your weight?"
"Let's discuss some weight loss strategies that might work for you."
"It sounds like you're saying that you feel uncomfortable around others."
"Have you always felt uncomfortable being overweight?"
The Correct Answer is C
A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. Ensure the formula is cold before administration. Enteral formula should be given at room temperature to avoid causing gastrointestinal cramping or discomfort. Cold formula can irritate the GI tract and lead to intolerance.
B. Check placement of the feeding tube by x-ray once daily. An x-ray is used initially to confirm tube placement after insertion, but daily x-rays are not required. Ongoing checks are done through aspirate checks and measuring external tube length.
C. Maintain the head of the client's bed at a 20° angle or higher. The head of the bed should be elevated to at least 30 to 45 degrees to prevent aspiration. A 20° angle is insufficient and increases the risk of aspiration pneumonia.
D. Check gastric residuals every 4 hr. This is appropriate for clients receiving continuous feedings. Monitoring gastric residual volume (GRV) every 4 hours helps assess tolerance to the feeding and reduces the risk of aspiration.
E. Change the feeding container and tubing every 24 hr. To prevent bacterial contamination, the feeding bag and tubing should be changed every 24 hours when using an open system. This is a standard infection control practice.
Correct Answer is A
Explanation
A. Wear loose-fitting clothing. After ICD implantation, the site may be sore or swollen, and tight clothing can cause irritation or pressure. Loose-fitting clothes help protect the incision and device, reducing discomfort and risk of complications.
B. Return in two weeks for a follow-up MRI. Most implantable cardioverter/defibrillators are not MRI-compatible unless specifically labeled as such. MRI exposure can interfere with device function and is generally avoided unless approved by a cardiologist.
C. Expect to have a rapid pulse rate for the first few weeks. The purpose of an ICD is to monitor and correct life-threatening arrhythmias, not to increase the heart rate. A rapid pulse is not expected and may indicate a complication requiring immediate evaluation.
D. Resume tub baths and swimming after 24 hr. Immersing the incision site in water within the first few weeks post-op increases the risk of infection. The client should avoid soaking the incision until it is fully healed, typically 1 to 2 weeks post-procedure.
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