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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 3-year-old walking on tiptoes: While some children may walk on their tiptoes occasionally, it's not necessarily a cause for concern unless it's persistent or accompanied by other developmental delays.
B. 1.5-year-old attempting to scribble: This is a typical stage for exploring hand and finger movements, leading to early attempts at drawing.
C. 5-month-old with whole hand grasp: At this age, infants use their whole hand to grasp objects, which is a normal developmental step before developing a more refined pincer grasp.
D. 3.5-month-old with diminished Moro reflex. The Moro reflex is a normal reflex in newborns that typically disappears by around 4 to 6 months of age. A diminished or absent Moro reflex before this age could indicate neurological concerns or developmental delays. Referral to a healthcare provider is necessary for further evaluation.
Correct Answer is B
Explanation
A. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.
B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.
C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.
D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.
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