While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

"I am sorry you feel that way. Perhaps you'd like to return when you have more time."

"You sound angry. Would you like to tell me about it?"

Ignore the angry outburst and continue with the history questions.

Move closer and place a hand on the client's shoulder to demonstrate concern.

Answer and Explanation

The Correct Answer is B

A. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

While this response acknowledges the client's feelings, it may inadvertently dismiss the client's concerns and fail to address the immediate need for treatment. It's important for the nurse to engage with the client and explore their concerns rather than suggesting they come back later.

B. "You sound angry. Would you like to tell me about it?"

This response demonstrates empathy and acknowledges the client's emotions. By inviting the client to express their feelings further, the nurse opens the door for communication and understanding. It allows the nurse to explore the underlying reasons for the client's frustration and address their concerns.

C. Ignore the angry outburst and continue with the history questions.

Ignoring the client's emotional outburst may cause the client to feel unheard or invalidated, potentially escalating the situation further. It's essential for the nurse to address the client's concerns and emotions to maintain a therapeutic relationship and provide effective care.

D. Move closer and place a hand on the client's shoulder to demonstrate concern.

While physical touch can be comforting for some individuals, it's important to consider the client's preferences and boundaries, especially in a situation where the client is expressing frustration or impatience. Approaching the client physically without consent may not be appropriate and could further exacerbate the situation.

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Correct Answer is C

Explanation

A. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

A. Open-ended question. B. Clarification. C. Empathizing. D. Paraphrasing.

Correct Answer is C

Explanation

A. Open-ended question. This response is not an open-ended question. Open-ended questions typically invite the client to share more information or elaborate on their thoughts and feelings. Instead, the nurse's response acknowledges the client's feelings and demonstrates empathy without directly soliciting more information.

B. Clarification. This response is not clarification. Clarification involves seeking clarification or additional information to ensure understanding. The nurse's response does not seek clarification but rather acknowledges the client's emotions.

C. Empathizing. This response is empathizing. Empathizing involves recognizing and understanding the client's emotions and expressing empathy. The nurse's response acknowledges the client's difficult situation and validates their feelings of distress, demonstrating empathy and understanding.

D. Paraphrasing. This response is not paraphrasing. Paraphrasing involves restating the client's message in the nurse's own words to confirm understanding. The nurse's response does not restate the client's message but rather expresses empathy and validation of the client's emotions.

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While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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