A nurse is caring for a client who is visibly upset and tearful about a recent terminal diagnosis. Which of the following responses should the nurse make?

"I'm going to contact your family so they can be with you."

"I will stay with you for a while."

"I'm sorry you have to deal with this."

"When you feel better, we'll talk about your treatment options."

Answer and Explanation

The Correct Answer is B

A. "I'm going to contact your family so they can be with you.": While involving family is important, the nurse should first provide emotional support to the client. It may feel abrupt to the client if the nurse immediately redirects the focus to others without acknowledging the client's current emotional state.

B. "I will stay with you for a while.": This is correct. Offering presence and emotional support by staying with the client is an appropriate response. It shows empathy and provides the client with comfort in a time of emotional distress.

C. "I'm sorry you have to deal with this.": This is less supportive. While it acknowledges the difficulty of the situation, it could unintentionally invalidate the client’s feelings by focusing on the nurse’s perspective rather than the client's experience.

D. "When you feel better, we'll talk about your treatment options.": This is not an appropriate response. It minimizes the client’s current emotional needs and may make the client feel that their feelings are not being prioritized. The focus should be on emotional support first.

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Correct Answer is B

Explanation

A. The client's potassium level is 2.7 mEq/L is incorrect. A potassium level of 2.7 mEq/L is low and indicates hypokalemia, which is a life-threatening condition that can occur in anorexia nervosa, particularly if the client is engaging in behaviors like purging. This level should be addressed immediately, not considered a positive outcome.

B. The client resumes menstruation is correct. The resumption of menstruation is a positive outcome of treatment for anorexia nervosa. It indicates that the client's nutritional status has improved and that the body is starting to regain normal function after addressing issues like malnutrition and hormonal imbalances.

C. The client's pulse rate is 44/min is incorrect. A pulse rate of 44/min is bradycardia, which is a common sign of anorexia nervosa due to malnutrition and the body's attempt to conserve energy. While it may improve with treatment, this finding would not be considered a positive outcome.

D. The client develops lanugo is incorrect. Lanugo (fine, soft hair) typically develops in severe anorexia nervosa due to malnutrition and is a sign of starvation. The appearance of lanugo is not a positive outcome but rather a compensatory mechanism to retain heat, indicating that the client is still in a malnourished state.

A. Apply rubber-soled slippers before ambulation. B. Determine the client's ability to use the call light. C. Create a schedule with an assistive personnel to do hourly rounding for the client. D. Move the bedside table with the client's personal items close to the bed.

Correct Answer is B

Explanation

A. "Apply rubber-soled slippers before ambulation.": This is important for safety, but it is not the first step in fall prevention. The client needs to be able to call for assistance if needed before moving around.

B. "Determine the client's ability to use the call light.": This should be the first step. Ensuring that the client can easily use the call light in case they need help is a foundational fall prevention strategy. It is essential for maintaining the client’s safety and enabling them to request assistance when needed.

C. "Create a schedule with an assistive personnel to do hourly rounding for the client.": Hourly rounding is an important fall prevention measure, but it should follow initial steps such as ensuring the client can call for help. It can be implemented after determining how the client will communicate needs.

D. "Move the bedside table with the client's personal items close to the bed.": This is a helpful precaution, as it reduces the need for the client to reach or stand to access their belongings. However, the most critical initial step is ensuring the client can safely summon help if needed.

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A nurse is caring for a client who is visibly upset and tearful about a recent terminal diagnosis. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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