A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

“You will not be able to eat breakfast until after you are washed.”.

“Please tell me what is worrying you at this time.”.

“I am going to wash you now and then you will take your medications.”.

“Why are you crying again? We haven’t touched you yet.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.

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Correct Answer is D

Explanation

Choice A rationale
Cherry jello is not a part of a full-liquid diet. While it is soft and easy to swallow, it does not provide the necessary nutrients that a patient recovering from surgery for laryngeal cancer would need.
Choice B rationale
Clear broth soup is part of a clear liquid diet, not a full liquid diet. A full liquid diet includes foods that are liquid at room temperature or melt at body temperature.
Choice C rationale
Chicken noodle soup is not suitable for a full-liquid diet. The noodles and chicken pieces could pose a swallowing risk for a patient recovering from surgery for laryngeal cancer.
Choice D rationale
Cream of potato soup is a suitable choice for a full-liquid diet. It is smooth and easy to swallow, and it provides necessary nutrients.

A. Offer high-protein and high-carbohydrate foods frequently. B. Administer low-flow oxygen continuously via nasal cannula. C. Encourage oral intake of at least 3,000 mL of fluids per day. D. Reposition and place the client in a prone position.

Correct Answer is A

Explanation

Choice A rationale
Offering high-protein and high-carbohydrate foods frequently is an important intervention for a client who has acute respiratory distress syndrome (ARDS)4. These nutrients can provide the energy needed for the increased metabolic demands of ARDS and support the healing process.
Choice B rationale
Administering low-flow oxygen continuously via nasal cannula is not typically the main treatment for ARDS5. ARDS is a severe condition that often requires high levels of supplemental oxygen delivered through methods that can provide higher concentrations of oxygen than a nasal cannula.
Choice C rationale
Encouraging oral intake of at least 3,000 mL of fluids per day is not a typical intervention for a client with ARDS4. While adequate hydration is important, too much fluid can worsen lung function in clients with ARDS4. Fluid management in ARDS is typically carefully controlled and may involve diuretics to remove excess fluid.
Choice D rationale
Repositioning and placing the client in a prone position is not a typical intervention for all clients with ARDS4. While some clients with severe ARDS may benefit from prone positioning, this is not a standard intervention for all clients with ARDS4.

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A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client after surgery for laryngeal cancer about a full liquid diet. What selection made by a client indicates to a nurse that the teaching was effective?

Correct Answer is D

Explanation

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

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A nurse is taking a class about patient safety. Which of the following statements is true regarding patient safety and prevention of harm?

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A nurse is analyzing arterial blood gas results for a client diagnosed with chronic obstructive pulmonary disease (COPD). What abnormal finding should the nurse anticipate?

A nurse is caring for a patient who reports experiencing an alteration in sense of smell following surgery for a total laryngectomy. The nurse should address the patient’s concern through which of the following responses?