The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence?
Prevent the nurse from saying the wrong thing.
Prompt the client to talk when he or she is ready.
Determine if the client would prefer to talk with another person.
Allow time for the client to drift off to sleep.
The Correct Answer is B
Choice A rationale
While silence might help a nurse avoid impulsive or unhelpful comments, its primary clinical purpose is not self-censorship. Therapeutic communication focuses on the needs and progress of the client rather than the nurse’s internal struggles with what to say next. Using silence as a shield against saying the wrong thing is a defensive posture rather than a proactive therapeutic tool. Effective silence is a deliberate choice made to facilitate the patient's own processing and expression.
Choice B rationale
Silence provides a quiet space that encourages the client to organize their thoughts and share their feelings at their own pace. It signals that the nurse is present, attentive, and willing to wait, which reduces the pressure on the client to speak quickly. This technique is especially useful when discussing sensitive or emotional topics, as it allows the individual to lead the conversation and find the words they need to describe their internal experiences or concerns.
Choice C rationale
Silence is not intended to be an awkward gap that suggests a lack of rapport or a need for a different healthcare provider. If a client prefers to speak with someone else, that should be addressed through direct communication or observation of the client's comfort levels. Using silence to test whether a patient wants another nurse is an inefficient and potentially confusing approach. Therapeutic silence should instead foster a sense of safety and openness within the current relationship.
Choice D rationale
While a quiet environment is necessary for rest, therapeutic silence is a communication strategy used during active interaction. If the goal is to allow the patient to sleep, the nurse would typically leave the room or dim the lights rather than sitting in silence as a communication technique. Silence in therapy is about engagement and active listening without verbal interruption, aimed at promoting psychological insight and verbalization rather than physical sleep or unconsciousness for the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Phosphate levels are generally not the primary concern when administering loop diuretics like furosemide. While diuretics can affect various electrolytes, the most significant life-threatening imbalances caused by furosemide involve potassium and sodium. Normal serum phosphate ranges from 3.0 to 4.5 mg/dL. While it is important to monitor overall metabolic status in heart failure patients, phosphate does not have the same immediate impact on cardiac rhythm and muscle function as potassium does during diuretic therapy.
Choice B rationale
Carbon dioxide levels in a metabolic panel reflect the bicarbonate concentration and the acid-base balance of the blood. While loop diuretics can cause metabolic alkalosis, which would increase these levels, it is not the most critical parameter to check before a single dose. Normal venous carbon dioxide levels range from 23 to 30 mEq/L. The priority is to assess for electrolyte deficiencies that could cause immediate cardiac complications, making potassium a more vital laboratory value to review.
Choice C rationale
Bicarbonate levels are an indicator of the body's acid-base status. Furosemide can lead to contraction alkalosis, causing an increase in bicarbonate levels over time. Normal bicarbonate levels range from 22 to 28 mEq/L. While monitoring for alkalosis is part of long-term care for clients on diuretics, it is not the priority assessment before drug administration. The nurse must prioritize electrolytes that directly influence heart rate and rhythm in the context of heart failure and loop diuretic use.
Choice D rationale
Furosemide is a loop diuretic that inhibits the reabsorption of sodium, chloride, and water in the ascending limb of the loop of Henle, leading to increased excretion of potassium. Normal serum potassium levels are 3.5 to 5.0 mEq/L. Administering furosemide to a client with hypokalemia can lead to life-threatening cardiac arrhythmias. Because heart failure patients often take other medications like digoxin, low potassium significantly increases the risk of toxicity and must be verified before administration.
Correct Answer is A
Explanation
Choice A rationale
Negligence is defined as a failure to provide the standard of care that a reasonably prudent nurse would provide in a similar situation, leading to potential harm. Metoprolol is a beta-blocker that requires monitoring of vital signs because it decreases heart rate and blood pressure. By omitting the assessment, the nurse breaches the duty of care. Normal systolic blood pressure is typically 90 to 120 mmHg, and heart rate is 60 to 100 beats per minute.
Choice B rationale
Shouting and physically snatching an object from a client represents battery or assault rather than negligence. Battery involves intentional, non-consensual physical contact, while assault involves creating an apprehension of harmful contact. While the nurse's behavior is unprofessional and violates client rights to autonomy and dignity, it is classified as an intentional tort. Negligence is usually an unintentional failure to perform a required nursing action, such as an assessment or safety check, rather than an aggressive outburst.
Choice C rationale
This action constitutes battery and a violation of the right to informed consent. Administering medications secretly after a competent client has refused is an intentional act of deception and physical violation. Ethical principles of autonomy dictate that an alert and oriented client has the absolute right to refuse any treatment. Hiding medication in food or drink is an intentional tort, which differs from negligence, where the nurse accidentally forgets a standard protocol or safety procedure.
Choice D rationale
Restraining a client against their will without a specific medical order or emergency justification constitutes false imprisonment. This is an intentional tort where a person is restricted in their personal liberty without legal authority. Negligence involves a lack of proper care or attention to detail, whereas applying restraints to a person who wants to leave is a deliberate restriction of movement. The nurse must follow strict protocols and obtain provider orders to legally apply any restrictive devices.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.