Although the client denies pain, the Practical Nurse (PN) observes the client is breathing rapidly with clenched fists and is grimacing. The PN’s best response to his observations would be: * Select one answer
“Where do you hurt?”
"I am glad you are feeling beter and have no discomfort.”
"What you are saying and what I am observing don’t seem to match.”
"It makes me uncomfortable when you are not honest with me.”
The Correct Answer is C
Choice A reason: “Where do you hurt?” is not the best response to the PN’s observations. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows confrontation, which is a communication technique that involves challenging or opposing the other person’s statements or behaviors. It may make the client feel defensive, pressured, or misunderstood, and may discourage further communication. Therefore, this choice is incorrect.
Choice B reason: "I am glad you are feeling beter and have no discomfort.” is not the best response to the PN’s observations. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows inconsistency, which is a communication barrier that involves giving contradictory or conflicting messages. It may make the client feel confused, ignored, or invalidated, and may undermine the trust or rapport between the client and the PN. Therefore, this choice is incorrect.
Choice C reason: "What you are saying and what I am observing don’t seem to match.” is the best response to the PN’s observations. This response shows reflection, which is a communication technique that involves restating or paraphrasing what the client has said to show understanding and clarify meaning. It also shows congruence, which is a communication skill that involves using consistent verbal and nonverbal cues to reinforce the message and avoid confusion or misunderstanding. It helps the client to recognize and explore their own feelings or thoughts, and shows that the PN is atentive, respectful, and empathetic. Therefore, this choice is correct.
Choice D reason: "It makes me uncomfortable when you are not honest with me.” is not the best response to the PN’s observations. This response shows self-disclosure, which is a communication technique that involves sharing personal information or feelings with the other person. It also shows accusation, which is a communication barrier that involves blaming or criticizing the other person for their statements or behaviors. It may make the client feel
guilty, ashamed, or angry, and may damage the relationship or communication between the client and the PN. Therefore, this choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.
A. An abduction pillow is placed between the client's legs when positioned is correct and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.
C. A turning sheet used under the client for turning and repositioning is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.
D. The UAPs keep their backs straight and knees bent when moving the client is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.
Correct Answer is D
Explanation
Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.
Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.
Choice C reason: Signs of fluid overload are objective data that indicate excess fluid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,
kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of fluid overload, but signs of fluid deficit or heat stroke. Therefore, this choice is incorrect.
Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.
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