A nurse is conducting a health assessment on a newly admitted patient. The patient appears anxious and begins to speak in a rushed and disorganized manner. Which of the following responses by the nurse demonstrates therapeutic communication?
"You need to calm down so I can complete this assessment properly."
"Please stop talking so fast; I can't understand you."
"I understand that you're nervous, but we need to hurry so we can finish the assessment."
"I can see you're feeling anxious. Take your time, and we can go through this together."
The Correct Answer is D
Rationale:
A. Telling the patient to calm down in a directive or commanding way is non-therapeutic. It may increase anxiety, create defensiveness, and hinder communication. This approach does not validate the patient’s feelings or support a collaborative interaction.
B. Asking the patient to stop talking quickly because the nurse cannot understand them focuses on the nurse’s needs rather than the patient’s feelings. It is judgmental and non-therapeutic, and it may make the patient feel dismissed or unheard.
C. While this response acknowledges the patient’s nervousness, emphasizing the need to hurry is not therapeutic. It increases pressure on the patient and may exacerbate anxiety, rather than helping them slow down and organize their thoughts.
D. This response demonstrates therapeutic communication by validating the patient’s feelings ("I can see you're feeling anxious"), providing reassurance, and encouraging a collaborative approach ("Take your time, and we can go through this together"). It creates a supportive environment that helps the patient feel heard and safe, promoting more effective communication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The femoral triangle, located in the upper thigh near the inguinal ligament, is where the femoral artery runs and is palpated for the femoral pulse. It does not provide information about distal lower extremity circulation, so it is not used to assess the posterior tibial pulse.
B. The knee area corresponds to the popliteal artery, which is palpated behind the knee for the popliteal pulse. This site is deeper and more difficult to palpate, and it does not reflect circulation in the foot or ankle.
C. The posterior tibial pulse is located on the postero-medial aspect of the lower third of the leg, just behind the medial malleolus. Palpating here allows assessment of arterial blood flow to the foot and helps detect peripheral arterial disease in the lower extremities.
D. The area between the second and third toes is where the dorsalis pedis artery runs. Palpating this site assesses the dorsalis pedis pulse, not the posterior tibial pulse, and evaluates a different part of foot circulation.
Correct Answer is ["A","D"]
Explanation
Rationale:
A. Client reports nipple discharge for the past week is subjective because the nurse is relying on the client’s personal report of experiencing discharge. The nurse cannot verify this symptom without direct observation at the time of the assessment, and the timing and description come from the client’s own account.
B. Axillary lymph node enlargement observed is objective data. The nurse can directly observe or palpate the lymph nodes, measure size, and document enlargement. It is a tangible sign that does not rely on the client’s perception.
C. Skin dimpling noted near the nipple is also objective data. The nurse observes the abnormal contour or indentation of the breast skin during examination, which can be verified visually and documented.
D. Client reports breast tenderness before menstruation is subjective because it is based on the client’s personal experience of discomfort or pain, which the nurse cannot measure. Pain and tenderness are classic examples of subjective findings because they rely on the client’s report.
E. A 2-cm firm mass palpated in the right breast is objective data. The nurse can physically feel, measure, and document the mass. This finding is tangible and reproducible on examination.
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