A nurse is caring for a client who was recently diagnosed with breast cancer. The client states, "I feel so alone. I don't know how I will be able to deal with this." Which of the following responses should the nurse make?

"Most people in your situation are able to get through this."

"Why do you think you're feeling so alone?"

"Do you have anyone you can talk to about your diagnosis?"

"I am so sorry about your diagnosis. You must be devastated."

Answer and Explanation

The Correct Answer is C

A. "Most people in your situation are able to get through this.": This statement is dismissive and may minimize the client’s feelings, as it generalizes the experience.

B. "Why do you think you're feeling so alone?": Asking "why" may make the client feel defensive and pressured to justify their feelings, which is not therapeutic.

C. "Do you have anyone you can talk to about your diagnosis?" This response encourages the client to reflect on their support system, which may help reduce feelings of isolation. It also shows empathy and invites further conversation without making assumptions.

D. "I am so sorry about your diagnosis. You must be devastated.": While it shows sympathy, it assumes the client’s feelings and may inadvertently heighten the client’s sense of distress without providing support.

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Correct Answer is C

Explanation

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.

A. The client has legal authority to do so. B. The client does not have a mental health condition. C. The client was not coerced. D. The client signed in the nurse's presence. E. The client speaks the same language as the nurse.

Correct Answer is ["A","C","D"]

Explanation

A. The client has legal authority to do so: The nurse’s signature confirms that the client appears to have the legal capacity to consent.

B. The client does not have a mental health condition: This is not within the nurse’s purview to assess unless explicitly stated; mental capacity, not condition, is key.

C. The client was not coerced: The nurse’s signature also indicates the consent was given voluntarily, without coercion.

D. The client signed in the nurse's presence: The nurse’s signature confirms that the nurse witnessed the client’s signature.

E. The client speaks the same language as the nurse: Consent requires understanding, which can be provided through an interpreter, so this is not necessary.

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A nurse is caring for a client who was recently diagnosed with breast cancer. The client states, "I feel so alone. I don't know how I will be able to deal with this." Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

The absence of bowel sounds is established after listening for:

Correct Answer is C

Explanation

A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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