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?”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Implementation is a phase of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. The nurse’s actions do not reflect this phase, as they are not performing any interventions or activities, but rather observing and measuring the client’s condition. Therefore, this choice is incorrect.
Choice B reason: Evaluation is a phase of the nursing process that involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. It also involves comparing the actual outcomes with the expected outcomes, and modifying the plan of care if needed. The nurse’s actions reflect this phase, as they are assessing the client’s leg for signs of improvement or resolution of thrombophlebitis, and noting that the client is ready for discharge. Therefore, this choice is correct.
Choice C reason: Outcomes identification is a phase of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. The nurse’s actions do not reflect this phase, as they are not setting any goals, but rather evaluating whether they have been met.
Therefore, this choice is incorrect.
Choice D reason: Assessment is a phase of the nursing process that involves collecting and analyzing data about the client’s health status, history, and environment. It also involves identifying any factors that may affect the client’s health or well-being, and forming a nursing diagnosis. The nurse’s actions do not reflect this phase, as they are not collecting or analyzing any new data, but rather reviewing the existing data and confirming the diagnosis. Therefore, this choice is incorrect.
Correct Answer is ["A"]
Explanation
Choice A reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Long explanations can confuse and overwhelm the client, who may have difficulty processing and retaining information.
Choice B reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Asking one question at a time can help the client focus and respond more easily, without feeling pressured or frustrated.
Choice C reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Using short sentences can help the client understand and remember the message, without being distracted or confused by unnecessary words.
Choice D reason: This is incorrect because it shows that the PN is rude and disrespectful to the client’s hearing ability. Talking loudly can make the client feel annoyed or threatened, and may not improve communication if the client has hearing loss. The PN should talk in a normal tone and check for understanding.
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