A nurse is caring for a client who just had knee surgery 2 days ago and is scheduled for physical therapy (PT) now. The patient is nervous and crying. She does not want to get out of bed this morning. Which action by the nurse is most likely to be helpful in reducing the patient’s concerns?
Telling the patient, “We will talk more about this after you have had medications.”
Standing at the side of the bed saying, “Come on, you got to do this, everyone gets nervous.”
Sitting beside the patient and stating, “You seem distressed today, tell me a little about what has you upset, I have some time.”
Ignoring the patient’s distress and continuing with the scheduled therapy.
The Correct Answer is C
Choice A reason: This response is dismissive and delays addressing the patient’s emotional needs. While medications may help with pain, the patient’s anxiety and distress must be acknowledged and addressed immediately. Deferring the conversation does not provide therapeutic support.
Choice B reason: This response is inappropriate because it minimizes the patient’s feelings and pressures them to participate without addressing their concerns. Statements like “everyone gets nervous” lack empathy and do not validate the patient’s emotions.
Choice C reason: This is the correct response because it uses therapeutic communication. Sitting beside the patient, acknowledging distress, and inviting them to share feelings demonstrates empathy and builds trust. This approach helps reduce anxiety and allows the nurse to provide emotional support, which is critical for recovery and participation in therapy.
Choice D reason: Ignoring the patient’s distress is unsafe and unprofessional. Emotional well-being is an important part of recovery, and neglecting it can worsen anxiety, reduce cooperation, and negatively impact outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement reflects the “Situation” portion of SBAR, where the nurse describes the immediate issue or event. It does not represent the “Recommendation” section.
Choice B reason: This statement reflects the “Assessment” portion of SBAR, where objective data such as vital signs are communicated. It is not the “Recommendation.”
Choice C reason: This statement reflects the “Background” portion of SBAR, where patient history and relevant information are provided. It does not represent the “Recommendation.”
Choice D reason: This is the correct statement because the “Recommendation” portion of SBAR involves suggesting actions or interventions to address the patient’s condition. Recommending a culture and sensitivity test is an appropriate example of a recommendation.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Discussing patient care in public areas, such as elevators, risks exposure of confidential health information and violates HIPAA regulations.
Choice B reason: Attending a patient care conference with authorized health care providers is a protected environment for sharing patient information and does not violate HIPAA.
Choice C reason: Accessing a patient’s chart out of curiosity or personal interest is unauthorized and breaches patient confidentiality, constituting a HIPAA violation.
Choice D reason: Reminding staff to follow standard precautions is a part of professional patient care and infection control, not a violation of HIPAA.
Choice E reason: Discussing a patient’s specific medical details in a public area like a nurses’ station, where unauthorized individuals may overhear, constitutes a breach of confidentiality under HIPAA.
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