The nurse plans to teach a client newly diagnosed with diabetes mellitus how to inject insulin. Upon entering the room with the injection supplies, the nurse finds the client in tears. How should the nurse respond?
"Would you like to talk about what is bothering you?"
"Do you feel like practicing insulin injections now?"
"I know you are afraid, but I am here to help you."
"Before you can go home you must learn how to give insulin."
The Correct Answer is A
A. "Would you like to talk about what is bothering you?" This empathetic approach acknowledges the client's emotional state and opens the door for them to express their concerns, which might be related to the diagnosis, fear of injections, or other anxieties.
B. "Do you feel like practicing insulin injections now?" This disregards the client's emotional state and might be perceived as insensitive.
C. "I know you are afraid, but I am here to help you." While offering reassurance, it assumes the client's fear without allowing them to express their emotions.
D. "Before you can go home you must learn how to give insulin." This is a directive and doesn't address the client's emotional response. It's important to prioritize addressing their concerns before proceeding with teaching.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. While trapped air can be absorbed, crepitus can indicate underlying issues such as a pneumothorax or other trauma, so it should not be dismissed as insignificant.
B. Since this client has only a small area of crepitus, it probably is not a significant finding. The size of the area does not necessarily correlate with the severity of the underlying condition. Even a small area of crepitus should be investigated.
C. Crepitus is always abnormal and should be followed-up with a more detailed assessment. This is the most accurate interpretation. Crepitus indicates the presence of air in the subcutaneous tissues, which is always abnormal and warrants further investigation.
D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately. While a chest x-ray can be part of the assessment, stating that a fractured rib "often" creates crepitus might be misleading. Crepitus can arise from other conditions, and a thorough assessment is needed before determining the exact cause.
Correct Answer is B
Explanation
A. Request social services to make a home visit. This is important but not the immediate priority. It can be part of the long-term intervention plan once the immediate safety and health of the client are ensured.
B. Interview the client privately without the adult child present. This is the highest priority. It allows the nurse to assess for potential abuse or neglect without the influence or intimidation of the accompanying adult, ensuring the client can speak freely.
C. Complete a neurological and musculoskeletal assessment. This is important to assess the extent of the injuries and the client's overall physical health, but it follows the immediate need to ensure the client's safety and ability to speak freely about their situation.
D. Ask the client if an assisted living facility is an option for safety concerns. While exploring living arrangements is important for long-term safety, it is not the highest priority. Ensuring the client's immediate safety and obtaining accurate information about their situation takes precedence.
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