A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

"Aren't you interested in learning how to perform this test?"

"Let's talk about what forethinking."

"I'll discuss this with your partner instead."

"Is this something you think you can do?"

Answer and Explanation

The Correct Answer is B

Choice A Reason:

"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.

Choice B Reason:

"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.

Choice C Reason:

"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.

Choice D Reason:

"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.

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Correct Answer is A

Explanation

Choice A Reason:

"I might have headaches due to a decline in my estrogen levels." Is appropriate. During perimenopause, fluctuations and eventual decline in estrogen levels can contribute to various symptoms, including headaches or migraines, due to hormonal changes. This statement reflects an awareness of one of the possible effects of changing hormone levels during this stage.

Choice B Reason:

"The best time to perform a breast self-examination is on the first day of my period." Is not appropriate. While performing a breast self-examination regularly is essential for breast health, the first day of the period isn't necessarily the "best" time for everyone. It's more advisable to choose a consistent day each month that is convenient and easy to remember.

Choice C Reason:

"I can expect to have regular periods until I am in menopause." Is not appropriate. Perimenopause is characterized by irregular periods, which means that during this transitional phase, menstrual cycles often become less predictable in terms of timing, duration, and flow. Irregular periods are a hallmark of perimenopause, so expecting regularity until menopause is not accurate.

Choice D Reason:

"I should stop receiving Papanicolaou tests once I reach menopause." Is not appropriate. Papanicolaou (Pap) tests are essential for detecting cervical abnormalities, regardless of menopausal status. Women should continue to have regular Pap tests according to their healthcare provider's recommendations, as the risk of cervical cancer persists even after menopause.

A. "He appears anxious about the transfer." B. "He is allergic to sulfa." C. "His partner has been visiting." D. "He is voiding adequately."

Correct Answer is B

Explanation

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

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A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Correct Answer is B

Explanation

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