A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night.”. Which of the following responses should the nurse make?

"Lots of people feel ashamed to tell their secrets.”.

"You will feel better if you tell me what you did last night.”.

"Let's discuss what you feel embarrassed about.”.

"You shouldn't feel embarrassed to talk to me.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The response, "Lots of people feel ashamed to tell their secrets," is not the most therapeutic option because it does not directly address the client's need to discuss their feelings or concerns. It does offer some empathy but falls short in terms of encouraging communication and understanding.

Choice B rationale:

The response, "You will feel better if you tell me what you did last night," may come across as too direct and pressuring, which can be counterproductive in building trust with the client. It may make the client feel even more embarrassed or uncomfortable.

Choice D rationale:

The response, "You shouldn't feel embarrassed to talk to me," attempts to reassure the client but may invalidate their feelings and is not as therapeutic as the correct choice. It's important to acknowledge the client's emotions and provide them with a safe space to open up.

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Correct Answer is C

Explanation

Choice A rationale:

Having a flat affect is not a specific indicator of delirium. A flat affect may be seen in various mental health conditions and is not unique to delirium. Delirium is characterized by acute changes in cognitive function and awareness, and a flat affect alone does not fulfill the criteria for diagnosing delirium.

Choice B rationale:

The client's speech being slow and repetitious is not a specific finding that leads to a suspicion of delirium. While changes in speech can be observed in delirium, this finding alone is not sufficient to diagnose delirium. Delirium is more about changes in consciousness, attention, and cognition.

Choice D rationale:

The client's inability to recognize objects is not a specific indicator of delirium. Delirium is characterized by a fluctuating level of consciousness and changes in cognitive function. Inability to recognize objects might be a symptom of other conditions, but it is not a hallmark sign of delirium.

Choice C rationale:

The client's manifestations developing suddenly is a key indicator of delirium. Delirium is characterized by an acute and rapid onset of cognitive and perceptual disturbances. It is often caused by an underlying medical condition or medication side effects and is typically reversible. The sudden development of symptoms is a significant clue in suspecting delirium and should prompt further evaluation and intervention. .

A. Obtain consent from the client's family member. B. Inform the client that they have the legal right to refuse treatment at any time. C. Request another nurse to review the procedure with the client. D. Encourage the client to have the procedure.

Correct Answer is B

Explanation

Choice A rationale:

Obtaining consent from the client's family member is not the appropriate action in this scenario. The client has the right to make decisions about their own medical treatment, and the consent should come from the client themselves, not a family member.

Choice B rationale:

Informing the client that they have the legal right to refuse treatment at any time is the correct action. Informed consent is a fundamental principle of medical ethics, and the nurse should respect the client's autonomy and right to make decisions about their own healthcare.

Choice C rationale:

Requesting another nurse to review the procedure with the client may be helpful in providing additional information and support, but it does not address the client's right to refuse treatment. The primary responsibility is to ensure that the client is aware of their right to refuse.

Choice D rationale:

Encouraging the client to have the procedure goes against the principle of respecting the client's autonomy and right to make their own decisions about their healthcare. The nurse should not pressure the client into having the procedure.

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A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night.”. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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