During a health history intake, the client avoids eye contact and answers questions briefly. What should the nurse prioritize understanding the client's needs?
Conclude that the client is simply shy and proceed with a brief assessment
Ask the client why they are withholding information
Report the client's behavior to the healthcare team immediately
Use clarifying questions to explore their concerns in a respectful manner
The Correct Answer is D
Choice A reason: Concluding that the client is simply shy represents a premature diagnostic closure that ignores potential underlying pathological or psychological triggers. This assumption minimizes the clinical significance of nonverbal cues, such as the avoidance of eye contact, which could indicate anxiety, cultural nuances, or a history of trauma that requires a more comprehensive rather than a brief assessment.
Choice B reason: Asking the client why they are withholding information is an inherently confrontational and non-therapeutic communication technique. Such an approach uses "why" questions that often induce defensiveness and increase patient anxiety. This can severely damage the therapeutic alliance and hinder the collection of accurate subjective data necessary for an effective health history and subsequent clinical decision-making.
Choice C reason: Reporting the behavior to the healthcare team immediately is an overreaction that bypasses the nurse's primary responsibility to establish rapport. While documentation of nonverbal behavior is necessary, immediate reporting before attempting therapeutic intervention is premature. The nurse should first attempt to utilize communication strategies to understand the client's perspective and establish a baseline of trust.
Choice D reason: Using clarifying questions to explore concerns in a respectful manner is the gold standard for therapeutic communication when encountering nonverbal resistance. This approach allows the nurse to validate the client's feelings and investigate potential barriers to communication, such as fear or cultural differences, without being accusatory. It facilitates a patient-centered environment that encourages more detailed disclosure of health information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The dermis contains collagen, elastic fibers, and sensory receptors, as well as blood vessels that assist in thermoregulation through vasodilation and vasoconstriction. However, it does not provide the primary cushioning or bulk insulation required to protect internal organs from mechanical trauma or significant environmental temperature shifts as effectively as the deeper adipose tissue layer.
Choice B reason: The stratum corneum is the outermost layer of the epidermis, consisting of dead, keratinized cells. Its primary physiological function is to serve as a barrier against environmental hazards, pathogens, and transepidermal water loss. It lacks the thickness, vascularity, and fatty composition necessary to contribute significantly to internal organ cushioning or systemic thermal insulation.
Choice C reason: The epidermis is the superficial, non-vascularized layer of the skin that provides a protective shield and regulates water retention. While it is vital for protection against external insults, it does not contain the adipose tissue needed for shock absorption or the substantial caloric reserves required for long-term maintenance of core body temperature.
Choice D reason: The subcutaneous layer, also known as the hypodermis, consists largely of adipose tissue and connective tissue. This layer acts as a highly efficient thermal insulator to retain body heat and serves as a mechanical shock absorber. This cushioning effect is essential for protecting underlying muscles, bones, and internal organs from external impact and injury.
Correct Answer is B
Explanation
Choice A reason: A client receiving enteral feeding has a nutritional risk factor, but their ability to change positions independently significantly mitigates the risk of prolonged tissue ischemia. Mobility is a primary protective factor in the Braden Scale, as it allows for the natural redistribution of pressure over bony prominences, preventing capillary occlusion.
Choice B reason: An unresponsive client who only changes position occasionally is at the highest risk due to the combination of impaired sensory perception and physical immobility. Being unresponsive means they cannot feel or react to the pain associated with tissue hypoxia, leading to prolonged pressure that exceeds capillary closing pressure, which rapidly causes cellular necrosis.
Choice C reason: A client who makes frequent changes in position and is ambulatory is at the lowest risk among the group. Active movement and walking maintain adequate peripheral circulation and ensure that no single area of skin is subjected to the sustained pressure required for the formation of stage 1 or deeper pressure injuries.
Choice D reason: While poor nutritional intake (eating only 25% of meals) is a recognized risk factor for skin breakdown, being alert and responsive allows the client to shift their weight in response to discomfort. Sensory perception and the ability to move independently are more significant predictors of immediate pressure injury risk than isolated nutritional deficits in an alert patient.
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