The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

"Is there any particular reason why you think this is your fault?"

"With surgery, your baby should have a full recovery."

"This must be a very difficult time for you."

"You did nothing wrong."

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. “This must be a very difficult time for you.”

Choice A rationale:

Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.

Choice B rationale:

While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.

Choice C rationale:

This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.

Choice D rationale:

Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.

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Correct Answer is ["C","D"]

Explanation

Choice A rationale: A shuffling gait increases fall risk but does not directly impair ability to perform foot care or toenail trimming, so UAP assignment is not primarily indicated here.

Choice B rationale: Urinary incontinence affects bladder control, not manual dexterity or safety during foot care. It does not necessitate UAP assistance for toenail trimming or routine foot care.

Choice C rationale: Syncope when bending increases risk of fainting during foot care tasks, making independent toenail trimming unsafe. UAP support ensures safety and prevents injury during routine care.

Choice D rationale: Hand tremors impair fine motor control, making toenail trimming difficult and unsafe. UAP assistance is indicated to prevent injury and ensure proper routine foot care.

A. Get the most difficult questions over with first. B. Begin with questions that are less sensitive in nature. C. Ask questions in a vague, non-specific format. D. Share personal values to put the client at ease.

Correct Answer is B

Explanation

Choice A reason: Starting with the most difficult questions can make the client uncomfortable and less likely to be open in the discussion.

Choice B reason: Beginning with less sensitive questions can help build rapport and make the client feel more comfortable discussing more intimate details later in the interview.

Choice C reason: Asking questions in a vague, non-specific format can lead to confusion and may not yield the necessary information.

Choice D reason: Sharing personal values is not appropriate as it can bias the interaction and may make the client feel judged or uncomfortable.

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The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["C","D"]

Explanation

When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?

Correct Answer is B

Explanation

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?