A client states “I don’t want to have surgery.” Which of the following is a therapeutic response to the client?
“Surgery is your only choice. You need this operation.”.
“Whether or not you have the surgery is your choice. What is your understanding of the situation?”.
“I hear you.
I wouldn’t want surgery either.
The Correct Answer is B
What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.
Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.
Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.
Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.
This will also help contain the fire and prevent it from spreading.
Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.
Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.
Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.
Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.
The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.
Correct Answer is D
Explanation
A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.
The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.
Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.
Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.
Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.
Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.
Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.
Beta-blockers can lower blood pressure, heart rate, and cardiac output.
They are not indicated for hypovolemia and can worsen the client’s condition.
To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.
For example: “I am (name), the nurse caring for (client name) in room (number).
I am calling because I am concerned that the client has developed hypovolemia after surgery.”
Background: Provide relevant and brief information related to the situation.
For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.
Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”
Assessment: Share your analysis and considerations of options. For
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