A nurse is caring for a client who states, "The doctor says I need to have surgery to replace the bones in my knee and I'm terrified." Which of the following therapeutic responses should the nurse make?

"Your doctor has been performing this surgery for a long time now."

"Would it help you to talk more with me about how you feel?"

I have prayed for you and everything is going to be fine."

"Why are you afraid to have surgery all of a sudden?"

Answer and Explanation

The Correct Answer is B

A. "Your doctor has been performing this surgery for a long time now." While this statement aims to reassure the client by emphasizing the doctor's experience, it does not address the client's feelings or encourage further discussion about their fears.
B. "Would it help you to talk more with me about how you feel?" This is a therapeutic response that encourages the client to express their feelings and concerns, showing empathy and providing an opportunity for the client to discuss their fears in more detail.
C. "I have prayed for you and everything is going to be fine." While this statement may be comforting to some, it can be inappropriate and may not address the client's specific fears or promote open communication. It also assumes the client's belief system, which might not be the same as the nurse's.
D. "Why are you afraid to have surgery all of a sudden?" This response can be perceived as dismissive and might make the client feel judged or misunderstood. It does not encourage a supportive discussion about the client's fears.

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Correct Answer is D

Explanation

A. Give the client more than one choice for resolving the conflict. While providing choices can be beneficial in some situations, it is not a direct action to ensure immediate environmental safety when a client is escalating aggressively.
B. Move toward the client using an aggressive stance. This approach is inappropriate and can escalate the situation further. A calm and non-threatening demeanor is essential in managing an aggressive client.
C. Choose two staff members to represent the staff and speak to the client. Having multiple staff members engage with an agitated client can sometimes help, but it’s crucial that any interaction is done calmly and without escalating the situation.
D. Stand between the client and the doorway of the room. This is the most appropriate action to ensure safety. Positioning yourself between the client and the exit can prevent the client from leaving the room and potentially harming themselves or others while ensuring a safe space to de-escalate.

A. Avoid using moisturizers on the client's skin. B. Place the client on a timed voiding schedule. C. Place the client in high-Fowler's position while in bed. D. Wash urine off the client's skin with hot water and soap.

Correct Answer is B

Explanation

A. Avoid using moisturizers on the client's skin. Moisturizers are important for maintaining skin integrity, especially in clients with incontinence, to prevent skin breakdown.
B. Place the client on a timed voiding schedule. This is correct. A timed voiding schedule can help manage incontinence by reducing the frequency of wetness and thereby preventing skin breakdown.
C. Place the client in high-Fowler's position while in bed. High-Fowler’s position is not typically indicated for preventing skin breakdown and can increase pressure on the sacral area.
D. Wash urine off the client's skin with hot water and soap. Washing with hot water and soap can be harsh and irritating to the skin. It is better to use mild soap and lukewarm water.

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A nurse is caring for a client who states, "The doctor says I need to have surgery to replace the bones in my knee and I'm terrified." Which of the following therapeutic responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is sitting with a group of clients in a meeting room. A client suddenly jumps up and begins yelling angrily. Which of the following actions should the nurse take to ensure environmental safety?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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