A nurse is caring for a client who is receiving end-of-life care. The client states, "The nurses here don't do a good job caring for me." Which of the following responses should the nurse make?

"Have you talked to your family about your diagnosis?"

"These feelings are an expected part of anticipatory grieving."

"I'm sure the nurses are trying to take good care of you."

"Can you tell me more about what is upsetting you?"

Answer and Explanation

The Correct Answer is D

Choice A reason: While discussing the client's diagnosis with their family could be part of the care process, it does not address the client's immediate concern about the quality of care they are receiving. This response does not validate the client's feelings or provide an opportunity for them to elaborate on their concerns.

Choice B reason: Telling the client that their feelings are part of anticipatory grieving may be true, but it can come across as dismissive and does not offer support for the specific issue the client has raised about the quality of care.

Choice C reason: Assuring the client that the nurses are trying to provide good care does not acknowledge the client's perception of inadequate care. It's important to validate the client's feelings and understand their perspective before offering reassurances.

Choice D reason: Asking the client to elaborate on their concerns shows empathy and a willingness to listen. It allows the nurse to gather more information about the client's experience and identify specific areas that may need improvement in the care provided.

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Correct Answer is C

Explanation

Choice A reason: While stress reduction techniques are important, they are not the immediate priority when a client is currently being aggressive.

Choice B reason: Role modeling is a long-term strategy and not appropriate for immediate intervention during an aggressive incident.

Choice C reason: This is the priority action to assess the risk of harm to others and to take necessary steps to ensure safety for all clients in the facility.

Choice D reason: Making a list is a reflective activity that may be part of a treatment plan but is not the priority action during an episode of aggression.

A. Ask the client what they are hearing. B. Focus the client on reality-based topics. C. Take the client for a walk outside. D. Encourage the client to listen to music.

Correct Answer is A

Explanation

Choice A reason: Asking the client about their hallucinations can provide valuable information about the content and nature of the hallucinations. This can help the nurse assess the client's current mental state and the potential impact of the hallucinations on their behavior and safety.

Choice B reason: Focusing the client on reality-based topics is a strategy that can be used after understanding the client's hallucinations. It's important to first acknowledge the client's experience before attempting to redirect their attention.

Choice C reason: Taking the client for a walk may be a good distraction technique, but it should not be the first action. The nurse needs to assess the client's safety and the potential risks associated with the hallucinations before engaging in activities.

Choice D reason: Encouraging the client to listen to music can be a therapeutic intervention to help distract from hallucinations. However, it is not the first action to take. The nurse should first understand the client's experience and ensure their safety.

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A nurse is caring for a client who is receiving end-of-life care. The client states, "The nurses here don't do a good job caring for me." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

Correct Answer is C

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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