During a client interview, the nurse notices the client repeatedly glancing at the clock and avoiding direct eye contact. Based on active listening principles what should the nurse do next?
End the interview to allow the client to reschedule.
Continue asking questions to complete the interview as quickly as possible.
Ask the client, I noticed you seem distracted. Is there something on your mind?"
Ignore the behavior and continue with the interview.
The Correct Answer is C
Rationale:
A. End the interview to allow the client to reschedule is incorrect because prematurely ending the interview may prevent the nurse from gathering important information and can convey disinterest or a lack of support. Active listening requires engagement and responsiveness to the client’s cues.
B. Continue asking questions to complete the interview as quickly as possible is incorrect because rushing the interview ignores the client’s nonverbal cues and may lead to incomplete or inaccurate information. Active listening emphasizes attention to both verbal and nonverbal communication.
C. Ask the client, "I noticed you seem distracted. Is there something on your mind?" is correct because it demonstrates active listening and empathetic engagement. By acknowledging the client’s nonverbal cues, the nurse creates an opportunity for the client to express concerns, clarify distractions, and feel understood, which fosters trust and improves communication.
D. Ignore the behavior and continue with the interview is incorrect because ignoring nonverbal cues can lead to missed information and signals to the client that their feelings or discomfort are unimportant. Effective active listening involves observing and responding to both verbal and nonverbal behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Experienced nurses working independently on a research project is correct because a laissez-faire leadership style provides minimal direct supervision, allowing highly skilled and self-motivated staff to make decisions and manage their own work. This approach encourages creativity, autonomy, and independent problem-solving, which are well-suited to experienced nurses conducting research where innovation and initiative are valued.
B. Developing a new protocol for emergency situations is incorrect because this scenario requires structured guidance, clear direction, and strong leadership to ensure patient safety and consistency. A laissez-faire style could lead to confusion, errors, or delays in critical care processes.
C. Training new graduates in clinical skills is incorrect because novice nurses need close supervision, mentoring, and feedback to build competence. Laissez-faire leadership would likely result in inadequate instruction and potential safety risks.
D. A team of nurses developing a patient care plan collaboratively is incorrect because while collaboration is important, this scenario benefits more from a democratic or participative leadership style, where guidance and structured discussion are provided. Laissez-faire leadership may lead to lack of coordination and unclear accountability in team-based planning.
Correct Answer is D
Explanation
Rationale:
A. A client in heart failure with 2+ edema in the lower extremities is incorrect as this indicates mild fluid retention, which is concerning but not immediately life-threatening. The client should be monitored, but this is not the highest priority.
B. A client with pneumonia and a saturation of 92% is incorrect because while hypoxia requires attention, an SpO₂ of 92% is mildly decreased and can typically be managed with supplemental oxygen and monitoring. It is important but less urgent than severe electrolyte imbalance.
C. A post-op client with no bowel sounds in the last 12 hours is incorrect because absent bowel sounds may indicate ileus, which is concerning but generally not immediately life-threatening. It requires assessment and monitoring but is lower priority compared to severe electrolyte disturbances.
D. A client in renal failure with elevated serum potassium levels needing dialysis is correct because hyperkalemia is potentially life-threatening and can cause fatal cardiac arrhythmias. Clients with elevated potassium levels require immediate assessment and intervention to prevent cardiac arrest, making this the highest priority for the nurse at the start of the shift.
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