A nurse is performing a health assessment and notices the client is tearful and indecisive when answering questions. What therapeutic communication technique is most appropriate for the nurse to use in this situation?
Active listening
Therapeutic silence
Sharing information
Clarifying questions
The Correct Answer is B
Choice A reason: Active listening is a foundational component of all nursing interactions, but it requires the client to be verbalizing thoughts. When a client is tearful and struggling to find words (indecisive), the immediate priority is to provide a safe emotional space. Active listening should be paired with silence to allow the client the necessary time to process their emotions before they are expected to continue speaking.
Choice B reason: Therapeutic silence is the most appropriate intervention for an emotionally overwhelmed client. It demonstrates patience and empathy without pressuring the client to perform or answer questions immediately. This technique allows the client to regain composure and organize their thoughts, signaling that the nurse is comfortable with the client's emotional expression and is fully present in the moment to support them.
Choice C reason: Sharing information is a cognitive intervention that is often poorly timed when a client is in an emotional state. Providing facts or medical data while a client is tearful can be perceived as dismissive of their emotional distress. Information sharing should occur only after the client’s emotional needs have been acknowledged and they are in a more receptive psychological state.
Choice D reason: Clarifying questions are used to resolve ambiguities in communication, but asking them while a client is tearful and indecisive may increase their anxiety. Pressing for clarification when a client is struggling to articulate their feelings can be counterproductive, potentially leading the client to shut down further rather than opening up about the underlying cause of their distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Therapeutic silence is a powerful communication tool that conveys acceptance and patience. It provides the client with the necessary psychological space to process complex emotions or memories related to sensitive health information. This approach fosters a trusting nurse-client relationship, which often leads to more accurate and complete data.
Choice B reason: Moving quickly to the next question or providing a summary can be perceived by the client as dismissive or insensitive. This prevents the nurse from obtaining critical subjective data that may be vital for the care plan. Rushing the interview process often shuts down further communication on sensitive topics.
Choice C reason: Skipping essential health history questions to avoid awkwardness is a failure in the assessment phase. Sensitive topics, such as sexual health or substance use, are often critical to the diagnosis and treatment. The nurse must find a professional way to address these areas rather than ignoring them.
Choice D reason: Pressing a client for immediate answers is non-therapeutic and can be perceived as aggressive or judgmental. This approach increases the client's anxiety and defensiveness, making them less likely to share honest information. Effective data collection relies on the client feeling safe and respected throughout the interview.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Older adults actually experience a decrease in vascularity and blood supply to the dermis. This reduction in blood flow contributes to delayed wound healing, impaired thermoregulation, and a paler skin tone. An increase in blood supply is not a physiological characteristic of the normal aging process of skin.
Choice B reason: Aging leads to the atrophy of subcutaneous fat layers, particularly in the extremities. This decrease in subcutaneous tissue reduces the body's natural insulation and padding, making older adults more susceptible to hypothermia and increasing the risk of skin breakdown or pressure injuries over bony prominences during physical activity.
Choice C reason: The epidermal and dermal layers undergo significant thinning as a result of decreased cell replacement and collagen degradation. This increase in skin thinning results in a fragile integumentary system, often described as paper-thin skin, which is highly prone to shearing forces, skin tears, and mechanical trauma.
Choice D reason: There is a physiological decline in the function of sebaceous and eccrine glands in older adults, leading to reduced sebum production. This decrease in skin hydration causes the skin to become xerotic, scaly, and itchy, which compromises the skin's barrier function against environmental pathogens and irritants.
Choice E reason: Skin elasticity significantly decreases with age due to the loss and fragmentation of elastin and collagen fibers within the dermal matrix. This leads to increased skin sagging and wrinkling. An increase in elasticity is associated with youth, whereas senescence is characterized by a loss of tensile strength
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