During a client interview, a nurse notices the client appears anxious and is speaking rapidly. To practice active listening, what should the nurse do first?

Interrupt the client to slow them down

Start planning the next question to ask

Use non-verbal cues like nodding and maintain eye contact

Ask the client to repeat everything slowly.

Answer and Explanation

The Correct Answer is C

A. Interrupt the client to slow them down: Interrupting can hinder communication, increase anxiety, and reduce the client’s willingness to share important information. Active listening requires patience and presence.

B. Start planning the next question to ask: Focusing on the next question distracts the nurse from fully hearing and understanding the client’s current concerns. Active listening emphasizes attention to the client’s words, emotions, and cues in the moment.

C. Use non-verbal cues like nodding and maintain eye contact: Non-verbal behaviors such as nodding, leaning slightly forward, and maintaining eye contact demonstrate attentiveness and encourage the client to continue sharing. These cues help the nurse practice active listening and build rapport, especially when the client is anxious or speaking rapidly.

D. Ask the client to repeat everything slowly: While clarifying is sometimes necessary, asking the client to repeat themselves immediately may increase anxiety or frustration. Initial focus should be on attentive non-verbal listening to gather as much information as possible without interruption.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. There may be a shallow open ulcer, blister, or abrasion, but subcutaneous fat is not visible. The described wound is deeper, so it does not fit Stage II criteria.

B. Stage I: Stage I pressure injuries are characterized by intact skin with non-blanchable erythema. There is no tissue loss or ulceration, making this stage inconsistent with the wound described.

C. Stage III: Stage III pressure injuries involve full-thickness skin loss with visible subcutaneous fat. The wound extends below the dermis into the subcutaneous tissue, creating a deep depression. This description matches the characteristics of a Stage III pressure injury.

D. Stage IV: Stage IV pressure injuries involve full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Since the description mentions subcutaneous fat but no bone, tendon, or muscle exposure, Stage IV is not appropriate.

A. Following the pathway strictly, regardless of patient changes B. Adjusting the care plan when a patient's condition deteriorates unexpectedly C. Documenting a pathway deviation only if it improves the patient's condition. D. Using the critical pathway as a rigid schedule for patient interventions.

Correct Answer is B

Explanation

A. Following the pathway strictly, regardless of patient changes: Strict adherence without considering the patient’s evolving condition can compromise safety and individualized care. Critical pathways are guides, not rigid protocols.

B. Adjusting the care plan when a patient's condition deteriorates unexpectedly: Deviating from a critical pathway is appropriate when a patient’s clinical status changes. The nurse must use clinical judgment to modify interventions to meet the patient’s immediate needs while documenting and communicating the changes.

C. Documenting a pathway deviation only if it improves the patient's condition: All deviations, whether positive or negative, must be documented to maintain accountability, track outcomes, and inform future care planning. Selective documentation is not appropriate.

D. Using the critical pathway as a rigid schedule for patient interventions: Treating the pathway as a fixed schedule ignores patient variability. Effective use of critical pathways involves flexibility and adaptation based on individual patient responses.

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During a client interview, a nurse notices the client appears anxious and is speaking rapidly. To practice active listening, what should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has a pressure injury on the sacrum with visible subcutaneous fat and a deep depression below the skin level. What stage of pressure injury would you document?

Correct Answer is C

Explanation

A nurse is working in a healthcare facility that uses critical pathways to manage patient care. Which action by the nurse demonstrates an understanding of when to deviate from the critical pathway?

Correct Answer is B

Explanation

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