During a cardiac assessment, a patient begins to express concern about experiencing shortness of breath and chest pain. The patient says, "I'm so scared that something is really wrong with my heart." Which of the following is the best therapeutic communication response by the nurse?
"You're probably overthinking it. There's no need to be so anxious."
"It's normal to feel that way, but it's probably nothing serious. Let's focus on the assessment."
"Don't worry. The tests will show that everything is fine with your heart."
"I understand your concern. Let's talk about what you're feeling, and I'll explain what we're doing to assess your heart."
The Correct Answer is D
Rationale:
A. Saying "You're probably overthinking it. There's no need to be so anxious" is incorrect because it minimizes the patient's feelings and can make the patient feel dismissed. Therapeutic communication requires validation, not judgment.
B. Saying "It's normal to feel that way, but it's probably nothing serious. Let's focus on the assessment" is incorrect because it assumes the situation is not serious and does not address the patient’s emotional needs. This approach can reduce trust and increase anxiety.
C. Saying "Don't worry. The tests will show that everything is fine with your heart" is incorrect because it provides false reassurance. Premature reassurance without assessment is unsafe, especially when the patient is experiencing symptoms like shortness of breath and chest pain, which may indicate a cardiac emergency.
D. Saying "I understand your concern. Let's talk about what you're feeling, and I'll explain what we're doing to assess your heart" is correct. This response acknowledges the patient’s feelings, encourages expression of concerns, and provides information about the plan of care. It uses therapeutic communication by combining empathy, active listening, and patient education, which helps reduce anxiety and promotes trust.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Decreased serum calcium affects bone health and may lead to osteoporosis or muscle weakness, but it is not a direct factor in the development of pressure injuries. While poor calcium levels may indirectly affect mobility, pressure injuries are primarily caused by localized tissue ischemia rather than systemic calcium deficiencies.
B. Increased muscle mass actually provides more padding over bony prominences, which helps protect against pressure injury. Clients with well-developed musculature are generally at lower risk compared with those who have muscle wasting or atrophy.
C. Decreased circulation is a primary risk factor for pressure injury development. Impaired blood flow reduces oxygen and nutrient delivery to tissues, making skin and subcutaneous tissue more susceptible to ischemia and necrosis when exposed to prolonged pressure, friction, or shear. Clients with impaired mobility are especially vulnerable because they cannot shift positions effectively to relieve pressure.
D. Increased collagen strengthens connective tissue and promotes skin integrity. While insufficient or abnormal collagen can contribute to skin breakdown, increased collagen alone does not predispose a client to pressure injuries and is generally protective rather than harmful.
Correct Answer is B
Explanation
Rationale:
A. Capillary refill time does not directly measure oxygenation of arterial blood. Oxygenation is better assessed using tools such as pulse oximetry (SpO₂) or arterial blood gases (ABGs). A delayed refill does not specifically indicate oxygen levels but rather reflects how well blood is reaching peripheral tissues.
B. Normal capillary refill is typically less than or equal to 2 seconds in adults. A refill time of 5 seconds is significantly delayed, indicating that blood is not returning promptly to the capillaries. This suggests decreased peripheral perfusion, which may occur in conditions such as shock, hypovolemia, dehydration, peripheral vascular disease, or decreased cardiac output. This is a clinically important abnormal finding that requires further assessment.
C. Increased capillary blood flow would result in a faster (not slower) refill time, typically under 2 seconds. A 5-second refill clearly indicates the opposite—reduced blood flow to the extremities.
D. A refill time of 5 seconds is not normal. Normal capillary refill indicates adequate circulation and should occur within 2 seconds. A delayed refill is a warning sign of impaired circulation and should not be interpreted as normal.
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