A nurse is talking to a client to evaluate a chief complaint. A nurse notes the client is avoiding eye contact and has a tense posture. What action should the nurse take to establish rapport?
Ask the client why they are acting so nervous
Sit at the client's level and maintain an open posture
Continue the assessment without acknowledging the behavior
Inform the client that eye contact is necessary for the exam
The Correct Answer is B
Therapeutic communication involves the integration of verbal and non-verbal behaviors to foster a trusting nurse-client relationship and encourage the disclosure of clinical information. When a client demonstrates defensive posturing or anxiety, the nurse must modify their own physical presence to appear non-threatening, accessible, and empathetic to the client's emotional state.
A. Asking "why" questions often sounds accusatory and can cause the client to become more defensive or withdrawn. In nursing communication, "why" inquiries are generally considered non-therapeutic because they demand a justification for feelings that the client may not yet fully understand or feel comfortable sharing.
B. Sitting at the client's eye level reduces the perceived power imbalance and conveys that the nurse is giving the client their full, undivided attention. Maintaining an open posture, such as uncrossed arms and legs, signals receptivity and warmth, which helps de-escalate tension and facilitates the establishment of a therapeutic rapport.
C. Ignoring the client’s non-verbal cues is a missed opportunity to address underlying anxiety or discomfort that may be relevant to the chief complaint. Professional nursing practice requires the validation of the client's emotional state to ensure that the assessment is holistic and that the client feels safe.
D. Demanding eye contact is culturally insensitive and can be perceived as confrontational, further damaging the nurse-client bond. The nurse should respect the client's personal space and comfort levels, understanding that rapport is built through consistent, supportive presence rather than the enforcement of specific social behaviors.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Primary dementia, such as Alzheimer's disease, involves the progressive neurodegeneration of the cerebral cortex and hippocampus. This leads to the inevitable decline of cognitive domains, starting with short-term memory deficits and eventually eroding the patient's ability to recognize familiar environments, people, and the temporal passage of time.
A. Decreased auditory and visual acuity are typically associated with normal physiological aging or specific sensory organ pathologies, such as presbycusis or cataracts. While they may coexist with dementia, they are not primary manifestations of the neurodegenerative processes that characterize dementing illnesses in the brain.
B. While personality changes can occur in dementia, they do not typically manifest as a complete "opposite" of the original self in a predictable manner. Patients may become more withdrawn or aggressive, but describing it as a total reversal is clinically inaccurate compared to the hallmark sign of cognitive decline.
C. The hallmark of primary dementia is a slow, insidious onset of memory loss that worsens over time. Initially, the client may forget small details, but as the disease progresses, they lose the ability to orient to time, place, and eventually their own identity or family members' faces.
D. The display of emotions is a normal human characteristic and not a specific manifestation of dementia. While dementia patients may experience "sundowning" or emotional lability (rapid mood swings), the mere "display of emotions" is too general to be a specific clinical expectation of the disease process.
Correct Answer is B
Explanation
Peripheral edema is the clinical manifestation of fluid accumulation in the intercellular interstitial spaces, often secondary to heart failure, renal dysfunction, or venous insufficiency. Assessment requires the application of manual pressure over a bony prominence to determine the presence and depth of "pitting" caused by fluid displacement.
A. Observing skin color can provide information about oxygenation, perfusion, or chronic venous stasis (such as hemosiderin staining), but it does not confirm the presence of edema. Edema is a volumetric and tactile finding involving fluid volume excess, which cannot be accurately quantified through visual inspection of pigmentation alone.
B. Compressing the skin for 5 seconds over a bony area, such as the medial malleolus, allows the nurse to evaluate the degree of pitting. This technique is the gold standard for grading edema on a scale of 1+ to 4+, providing a measurable indication of the severity of fluid retention.
C. Abdominal girth measurement is a specific intervention used to monitor ascites, which is fluid accumulation within the peritoneal cavity, rather than peripheral edema. While both involve fluid shifts, measuring the waistline does not provide diagnostic information regarding the localized swelling of the lower extremities or ankles.
D. Palpating the dorsalis pedis pulse assesses arterial patency and peripheral perfusion rather than fluid volume in the tissues. While severe edema can make pulses difficult to palpate, the act of feeling for a pulse is not a diagnostic method for identifying or grading the accumulation of interstitial fluid.
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