A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?
"This unit has a policy against staff harassment."
"It is important to dress the right arm first."
"Dressing must be a frustrating experience for you."
"We will give you a class on dressing tomorrow."
Monitor the client's white blood cell count.
The Correct Answer is C
A. "This unit has a policy against staff harassment."
This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.
B. "It is important to dress the right arm first."
This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.
C. "Dressing must be a frustrating experience for you."
This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.
D. "We will give you a class on dressing tomorrow."
This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Auscultate the bowel sounds in all four quadrants:
Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.
B. Palpate the client's pedal pulse volume bilaterally:
Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.
C. Determine the elasticity of the client's skin turgor:
Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.
D. Observe the client's skin and mucous membranes:
This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.
Correct Answer is C
Explanation
A. Provide a numeric pain scale:
While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.
B. Observe body language and movement:
Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.
C. Ask the client to describe the pain:
This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.
D. Identify effective pain relief measures:
Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.
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