A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?
"I don't think that is really what is happening to you."
"Don't worry. Everything will be okay."
"How are things going at your job?"
"You must be feeling very frightened right now."
The Correct Answer is D
A. This statement dismisses the client's feelings.
B. Offering false reassurance is not therapeutic.
C. Changing the subject does not address the client's distress.
D. This is the correct answer. Acknowledging the client's feelings is a therapeutic response that encourages further discussion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Irritability – This is the expected finding. Newborns exposed to cocaine in utero often exhibit irritability, hypertonia, tremors, and a high-pitched cry due to withdrawal symptoms and central nervous system excitability.
B. Increased head circumference – Cocaine use is associated with intrauterine growth restriction (IUGR), leading to smaller head circumferences rather than increased head size.
C. Hypotonicity – Cocaine-exposed newborns typically exhibit hypertonicity (increased muscle tone) rather than hypotonia.
D. Decreased auditory startle response – These newborns usually have an exaggerated Moro (startle) reflex rather than a decreased response.
Correct Answer is A
Explanation
A. "I'll place him in the back seat facing the back seat." – This is the correct answer. Infants should always ride in a rear-facing car seat in the back seat until at least 2 years of age.
B. "I'll place him in the front seat facing the front of the car." – The front seat is not safe for infants due to airbag deployment risks.
C. "I’ll place him in the back seat facing the back of the front seat." – This wording is unclear, but the safest position is directly facing the back of the car.
D. "I’ll place him in the front seat facing the back of the car.” – Infants should not be placed in the front seat, even if rear-facing.
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