A client has been on the nursing unit for a few weeks because of complications after surgery, including the need for extensive wound care. During the last dressing change before discharge to home with home health services, the client becomes angry and says, “You don’t have to be so careful. I’m being sent home anyway!” Which response, if made by the nurse WOULD NOT be therapeutic? Select one answer

“I hear frustration or perhaps anger in your voice. Could you tell me more about how you are feeling right now?”

“It sounds as though you are nervous about going home, but the wound care nurse who will see you also uses excellent technique I am sure your wound will continue to heal.”

“Do you have any concerns about what will happen after discharge that you would like to talk about?”

“Many people who have been in the hospital for an extended period have mixed feelings about going home. Can you tell me how you are feeling about discharge?”

Answer and Explanation

The Correct Answer is B

Choice A reason: “I hear frustration or perhaps anger in your voice. Could you tell me more about how you are feeling right now?” is a therapeutic response, not a non-therapeutic one. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s emotions, and invites them to express their concerns or fears. Therefore, this choice is incorrect.

Choice B reason: “It sounds as though you are nervous about going home, but the wound care nurse who will see you also uses excellent technique I am sure your wound will continue to heal.” is a non-therapeutic response, not a therapeutic one. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It does not address the client’s emotions or needs, and may sound vague or insincere. Therefore, this choice is correct.

Choice C reason: “Do you have any concerns about what will happen after discharge that you would like to talk about?” is a therapeutic response, not a non-therapeutic one. This response shows open-ended questioning, which is a communication technique that involves asking questions that require more than a yes or no answer. It also shows support, which is a communication technique that involves providing emotional or practical assistance to the client, and helping them cope with their situation or problem. It encourages the client to share their thoughts and feelings, and shows that the nurse is interested, supportive, and empathetic. Therefore, this choice is incorrect.

Choice D reason: “Many people who have been in the hospital for an extended period have mixed feelings about going home. Can you tell me how you are feeling about discharge?” is a therapeutic response, not a non-therapeutic one. This response shows generalization, which is a communication technique that involves using statements that apply to most people in similar situations. It also shows reﬂection, which is a communication technique that involves restating or paraphrasing what the client has said to show understanding and clarify meaning. It helps the client to feel less alone or isolated, and to explore their own feelings or thoughts. Therefore, this choice is incorrect.

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Correct Answer is B

Explanation

Choice A reason: Ineﬀective thermoregulation is a nursing diagnosis that indicates a problem with the body’s ability to maintain a normal temperature range. It can be caused by factors such as infection, inﬂammation, or environmental exposure. It can result in symptoms such as fever, chills, sweating, or shivering. The client’s temperature of 102oF (38.9oC) suggests that they have ineﬀective thermoregulation, but it is not the highest priority nursing diagnosis, as it is not immediately life-threatening. Therefore, this choice is incorrect.

Choice B reason: Decreased cardiac output is a nursing diagnosis that indicates a problem with the amount of blood pumped by the heart per minute. It can be caused by factors such as arrhythmias, heart failure, or shock. It can result in symptoms such as hypotension, tachycardia, dyspnea, or oliguria. The client’s heart rate of 144 beats/minute and irregular suggests that they have decreased cardiac output, which is the highest priority nursing diagnosis, as it can lead to organ failure or death if not treated promptly. Therefore, this choice is correct.

Choice C reason: Ineﬀective breathing patern is a nursing diagnosis that indicates a problem with the rate, rhythm, depth, or quality of respirations. It can be caused by factors such as airway obstruction, lung disease, or anxiety. It can result in symptoms such as dyspnea, cyanosis, or hypoxia. The client’s respiratory rate of 22 breaths/minute is within the normal range and does not indicate an ineﬀective breathing patern. Therefore, this choice is incorrect.

Choice D reason: Ineﬀective renal tissue perfusion is a nursing diagnosis that indicates a problem with the blood ﬂow to the kidneys. It can be caused by factors such as renal artery stenosis, dehydration, or sepsis. It can result in symptoms such as oliguria, hematuria, or azotemia. The client’s vital signs do not indicate an ineﬀective renal tissue perfusion, and there is no evidence of renal impairment or dysfunction. Therefore, this choice is incorrect.

A. Gives the same message to the patient verbally and nonverbally B. Speaks firmly and positively C. Is unapologetic D. Agrees to do whatever the patient requests

Correct Answer is D

Explanation

Choice A reason: Gives the same message to the patient verbally and nonverbally is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using congruent verbal and nonverbal cues, such as eye contact, tone of voice, and body language, to reinforce the message and avoid confusion or misunderstanding. Therefore, this choice is incorrect.

Choice B reason: Speaks firmly and positively is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using firm and positive language, such as “I” statements, active verbs, and constructive feedback, to convey the message and avoid aggression or passivity. Therefore, this choice is incorrect.

Choice C reason: Is unapologetic is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings,

and needs in a clear, respectful, and confident manner. It also involves being unapologetic for one’s opinions, beliefs, or values, as long as they do not harm or disrespect others. It does not mean being rude or arrogant, but rather being honest and authentic. Therefore, this choice is incorrect.

Choice D reason: Agrees to do whatever the patient requests is a sign of needing further teaching on using assertive communication, not an example of it. Agreeing to do whatever the patient requests is a communication style that involves suppressing one’s thoughts, feelings, and needs in order to please or avoid conﬂict with others. It is a form of passive communication, which can lead to resentment, frustration, or loss of self-esteem. It can also compromise the quality of care or the safety of the patient or the nurse. Therefore, this choice is correct.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admited with the following vital signs: temperature 102oF (38.9oC); heart rate 144 beats/minute and irregular;, and respiratory rate 22 breaths/minute. Which nursing diagnosis takes highest priority when planning this client’s care? Select one answer

Correct Answer is B

Explanation

The nurse preceptor is instructing the new nurse on appropriate communication techniques. The new nurse indicates a need for further teaching on using assertive communication, if she does which of the following when communicating with patients? Select one answer

Correct Answer is D

Explanation

The nurse is preparing to explain an upcoming procedure to an English-speaking Latino client. The nurse determines that the best way to verbally communicate with this client is to:

The Practical Nurse (PN) is caring for a client with dementia and memory loss. Which of the following communication techniques would be most eﬀective? (Select all that apply)

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

Family members awaiting the outcome of a suicide atempt are tearful. Which response by the Practical Nurse (PN) is therapeutic to the family at this time? * Select one answer

A client with chronic renal failure is admited with a heart rate of 122 beats/minute; a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Select one answer

A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)

A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)