The nurse is caring for a client who lost his family in a fire. Upon entering the room, the client states angrily. "I hate this place. No one can help me." The nurse's best response would be:

"Please, don't be so angry. Things will get better."

"Maybe I can help. Tell me more about how you're feeling."

"I'm so sorry that you feel that way."

"You shouldn't talk like that."

Answer and Explanation

The Correct Answer is B

B. This is the best response. It demonstrates empathy, active listening, and a willingness to understand the client's emotions. By inviting the client to express their feelings further, the nurse creates an opportunity for therapeutic communication and can better assess how to support the client emotionally.

A. This response dismisses the client's feelings of anger and sadness and may come across as minimizing their emotions. It does not acknowledge the client's current state of distress or provide validation for their feelings.

C. This response expresses empathy and acknowledges the client's feelings, which is important. However, it may seem somewhat passive and could benefit from further exploration or invitation for the client to elaborate on their feelings.

D. This response is dismissive and judgmental. It may make the client feel invalidated or criticized for expressing their emotions, which can further escalate feelings of anger or distress.

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Correct Answer is B

Explanation

B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.

A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.

C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.

D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.

A. Meeting the client's spiritual needs can help decrease suffering. B. Nurses are the only health professionals who provide this type of holistic care. C. Until spiritual needs are met, physical needs cannot be healed. D. It is important that the nurse's idea of spirituality matches the client's ideas.

Correct Answer is A

Explanation

A. Spiritual care is integral to holistic care. Addressing spiritual needs can provide comfort, meaning, and a sense of peace to clients, which can contribute to a reduction in suffering, both physical and emotional. Spiritual distress can exacerbate physical symptoms and affect overall well-being, so addressing these needs can lead to better outcomes.

B. While nurses play a significant role in providing holistic care, including spiritual care, they are not the sole providers. Spiritual care can be provided by chaplains, spiritual counselors, and other healthcare professionals trained in addressing spiritual needs. However, nurses often have frequent and intimate contact with patients, making them well-positioned to assess and address spiritual concerns and to collaborate with other members of the healthcare team to meet these needs.

C. While addressing spiritual needs can contribute to overall well-being and healing, physical healing does not solely depend on meeting spiritual needs. Physical healing involves medical interventions, treatments, and physiological processes. However, addressing spiritual needs can positively impact a client's emotional and psychological state, which can support the overall healing process.

D. Understanding and respecting the client's own beliefs, values, and preferences regarding spirituality is crucial. Each individual may have unique spiritual beliefs and practices that influence their health beliefs and behaviors. The nurse should approach spiritual care with cultural sensitivity and respect for diversity, ensuring that the care provided aligns with the client's beliefs and preferences.

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The nurse is caring for a client who lost his family in a fire. Upon entering the room, the client states angrily. "I hate this place. No one can help me." The nurse's best response would be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Correct Answer is B

Explanation

As a part of care planning, the nurse considers the client's spiritual needs. What is the Rationale for this concern?

Correct Answer is A

Explanation

The phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:

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The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

Joint Commission (TJC) requires that a(n)

The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

The nurse is instructing family members of an immunosuppressed client who has been placed in a protective environment to wear gloves and a mask when visiting the client. The nurse is aware that this practice is important to prevent infection transmission from: