A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?
"Have you tried leaving your house just once per day?"
"Have you thought about moving to a new neighborhood?"
"Let's discuss how you feel when you leave your house."
"Tell me why you have developed an aversion to leaving your house."
The Correct Answer is C
Choice A Reason:
"Have you tried leaving your house just once per day?" This response assumes a potential solution without fully understanding the client's feelings. It doesn't encourage open discussion or exploration of the client's anxiety.
Choice B Reason:
"Have you thought about moving to a new neighborhood?" This response jumps to a significant life change as a solution without exploring the client's current situation and emotions. It may not be a practical or necessary step.
Choice C Reason:
"Let's discuss how you feel when you leave your house." This response is an open and therapeutic approach that encourages the client to express their feelings and thoughts about the situation. It allows the nurse to gather more information and better understand the client's anxiety related to leaving the house. The other options do not facilitate open communication or exploration of the client's feelings.
Choice D Reason:
"Tell me why you have developed an aversion to leaving your house." While this response is more open-ended, it phrases the question in a somewhat confrontational manner, which might make the client defensive. The previous response ("Let's discuss how you feel when you leave your house") is gentler and inviting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Documenting the infiltration is important for the client's medical record, but it should not be the first action when infiltration is suspected.
Choice B Reason:
Elevating the arm can help reduce swelling, but it should come after stopping the infusion.
Choice C Reason:
Applying a warm compress can help with comfort and may be done after stopping the infusion, but it is not the first action.
Choice D Reason:
Stop the infusion is correct. When a nurse observes signs of infiltration around an IV insertion site, such as edema and coolness of the skin, the first and most important action is to stop the infusion immediately. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. Stopping the infusion prevents further damage to the surrounding tissue and minimizes the risk of complications.
Correct Answer is A
Explanation
Choice A Reason:
The shortness of breath is correct. Albuterol is a bronchodilator medication commonly used to relieve symptoms of shortness of breath and wheezing in individuals with conditions such as asthma or chronic obstructive pulmonary disease (COPD). It helps to relax the muscles in the airways, allowing for easier breathing. It is not used to treat swelling of the lips, nausea, or hyperglycemia.
The other choices are not the answer because albuterol is specifically indicated for the treatment of respiratory symptoms like shortness of breath and wheezing associated with conditions like asthma or COPD. Here's why the other options are not correct:
Choice B Reason:
Swelling of the lips is incorrect. Albuterol is not used to treat lip swelling. Lip swelling may be related to allergies or other medical conditions, and treatment would depend on the underlying cause.
Choice C Reason:
Nausea is incorrect. Albuterol is not used to treat nausea. Nausea can have various causes, and treatment would depend on the underlying reason for the nausea.
Choice D Reason:
Hyperglycemia is incorrect. Albuterol does not treat hyperglycemia (high blood sugar). It is used for respiratory symptoms, not for managing blood sugar levels. Treatment for hyperglycemia typically involves medications such as insulin or oral antidiabetic agents, as well as dietary and lifestyle changes.
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