A nurse is assessing a client who is about to undergo a left lobectomy to treat lung cancer. The client expresses fear and regret about her past smoking habit.
How should the nurse respond?
"It's okay to feel scared. Let's talk about what you are afraid of."
"Don't worry. The important thing is you have now quit smoking."
"Your doctor is a great surgeon. You will be fine."
"I understand your fears. I was a smoker also."
The Correct Answer is A
Choice A rationale:
It's okay to feel scared. Let's talk about what you are afraid of.
Acknowledges the client's feelings: This response directly acknowledges the client's fear and regret, which is a crucial first step in providing emotional support. It validates the client's experience and creates a safe space for open communication.
Invites the client to share: By inviting the client to talk about their fears, the nurse encourages open expression of emotions. This can help the client to process their feelings and gain a sense of control over their situation.
Promotes understanding: By actively listening to the client's concerns, the nurse can gain a better understanding of their individual needs and fears. This understanding can then guide the nurse in providing tailored support and interventions.
Facilitates coping: Talking about fears can help the client to identify and explore coping strategies. The nurse can assist in this process by offering suggestions, providing resources, and teaching relaxation techniques.
Strengthens the nurse-client relationship: By demonstrating empathy, active listening, and support, the nurse can foster a trusting relationship with the client. This relationship can provide a source of comfort and reassurance during a challenging time.
Choice B rationale:
Don't worry. The important thing is you have now quit smoking.
Dismisses the client's feelings: This response minimizes the client's fear and regret, which can be invalidating and hinder emotional expression.
Focuses on the past: While it's important to acknowledge the positive step of quitting smoking, this response shifts the focus away from the client's current emotional state and concerns about the upcoming surgery.
Offers false reassurance: Telling the client not to worry can be unrealistic and unhelpful, as it doesn't address the underlying fears.
Choice C rationale:
Your doctor is a great surgeon. You will be fine.
Provides premature reassurance: While it's appropriate to express confidence in the medical team, this response may not fully address the client's emotional needs. It can also inadvertently downplay the seriousness of the surgery and potential risks.
Shifts focus away from the client: This response focuses on the surgeon's skills rather than the client's feelings and concerns.
Choice D rationale:
I understand your fears. I was a smoker also.
May be perceived as self-focused: While sharing a personal experience can sometimes build rapport, it's important to ensure the focus remains on the client's needs and experiences. This response could inadvertently shift the attention to the nurse's own story.
Does not directly address the client's fears: While expressing understanding can be helpful, it's important to follow up with s and encouragement to explore the client's specific concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Anger is a common and expected response to trauma, including sexual assault. It can stem from various sources, including:
Feelings of violation and powerlessness: Survivors may feel intense anger towards the perpetrator for taking control of their bodies and lives.
Betrayal: If the assault was committed by someone they knew or trusted, survivors may feel intense anger towards that person for breaking their trust.
Frustration and injustice: Survivors may feel angry at the injustice of the situation, the lack of control they had, and the ongoing impact of the trauma.
Difficulty processing other emotions: Anger can sometimes mask other emotions that are difficult to deal with, such as fear, sadness, or guilt.
Anger can manifest in various ways, including:
Irritability and outbursts: Survivors may have a short temper, snap at others easily, or have difficulty controlling their anger. Aggression: In some cases, anger can lead to physical or verbal aggression towards others or self-harming behaviors.
Withdrawal and isolation: Some survivors may withdraw from social interactions and relationships to avoid potential triggers for their anger.
Substance abuse: Some survivors may turn to alcohol or drugs to numb their feelings or cope with their anger.
Choice B rationale:
Sleeping 12 hours or more each day can be a symptom of PTSD, but it is not a specific indicator of anger. It can also be a sign of depression, anxiety, or hypersomnia, a sleep disorder characterized by excessive daytime sleepiness.
Choice C rationale:
PTSD can sometimes lead to an increased sense of detachment from others, rather than attachment. Survivors may feel emotionally numb, have difficulty trusting others, or withdraw from relationships.
Choice D rationale:
While some survivors of sexual assault may feel a need to talk about the event, it is not a universal symptom of PTSD. Some survivors may avoid talking about the event altogether due to the distress it causes.
Correct Answer is B
Explanation
Choice A rationale: Providing privacy when friends visit is a general good practice in nursing. However, it may not be the most effective intervention for a client with anorexia nervosa. Anorexia nervosa is characterized by a distorted body image and an intense fear of gaining weight. While privacy is important, it is not directly related to the management of anorexia nervosa.
Choice B rationale: Scheduling regular weigh-in times is a key intervention for clients with anorexia nervosa. Regular weigh-ins help monitor the client’s progress and any potential complications related to weight loss. This intervention is directly related to the management of anorexia nervosa and is therefore the correct answer.
Choice C rationale: Complimenting the client for weight gain can be a sensitive issue for individuals with anorexia nervosa. While it might seem like a positive reinforcement, it could potentially trigger anxiety and fear in the client, as individuals with anorexia nervosa have an intense fear of gaining weight. Therefore, this intervention should be handled with care and is not the best choice in this scenario.
Choice D rationale: Allowing the client to eat at any time might seem like a good idea, but it is not the most effective intervention for a client with anorexia nervosa. Individuals with anorexia nervosa often have strict rituals and rules around eating. Allowing them to eat at any time might not address these underlying issues and could potentially enable their disordered eating habits.
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