A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?

"That's a hurtful thing to say."

"Tell me more about that."

"Well, that's your opinion."

"Why would you say such a thing?".

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Focuses on the nurse's feelings rather than the client's needs. This response may make the client feel guilty or defensive, and it does not address the underlying cause of their anger or frustration.

Shuts down communication. Saying "That's a hurtful thing to say" can signal to the client that the nurse is not open to hearing their concerns, which can hinder the development of trust and rapport.

Fails to acknowledge the client's pain. The client is in a vulnerable position, experiencing both physical and emotional pain. This response does not recognize the validity of their experience, which can further alienate them.

Choice B rationale:

Invites the client to share their perspective. By saying "Tell me more about that," the nurse demonstrates a willingness to listen and understand the client's concerns. This can help to build trust and rapport, and it can provide valuable insights into the client's experience.

Promotes exploration of feelings. Allowing the client to express their feelings can help them to process their emotions and to feel more understood. This can lead to a greater sense of control and empowerment, which can be beneficial for their overall coping and healing.

Gathers information to tailor care. By listening to the client's concerns, the nurse can gain a better understanding of their specific needs and preferences. This information can then be used to adjust the plan of care to better meet the client's individual needs.

Choice C rationale:

Dismisses the client's feelings. Saying "Well, that's your opinion" minimizes the client's experience and sends the message that their feelings are not important. This can damage the therapeutic relationship and make the client feel even more isolated and unsupported.

Fails to address the underlying issue. This response does not attempt to explore the reasons for the client's anger or frustration, which means that the problem is likely to continue.

Choice D rationale:

Sounds accusatory and confrontational. Asking "Why would you say such a thing?" can put the client on the defensive and make them feel like they have to justify their feelings. This can hinder open communication and make it more difficult to address the root of the problem.

May make the client feel judged or criticized. This response can come across as judgmental and uncaring, which can further alienate the client and damage the therapeutic relationship.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale: Potassium level A therapeutic response to the treatment plan for anorexia nervosa would be indicated by a normal potassium level. Anorexia nervosa often leads to electrolyte imbalances, including low potassium levels, due to inadequate food intake and, in some cases, purging behaviors. Therefore, a normal potassium level can indicate that the client is responding well to the treatment plan, as it suggests they are maintaining a more balanced diet and managing their symptoms effectively.

Choice B rationale: Temperature While body temperature can be affected by severe malnutrition, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.

Choice C rationale: ECG report An ECG report can indicate a therapeutic response to the treatment plan for anorexia nervosa. This is because anorexia nervosa can lead to heart problems such as abnormal heart rhythms. Therefore, a normal ECG report can suggest that the client’s heart health is improving, which can be a sign that they are responding well to the treatment plan.

Choice D rationale: BUN level While the BUN (Blood Urea Nitrogen) level can provide information about hydration status and kidney function, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.

Choice E rationale: BMI BMI (Body Mass Index) is a key indicator of a therapeutic response to the treatment plan for anorexia nervosa. Anorexia nervosa is characterized by a significantly low body weight, and one of the main goals of treatment is weight restoration. Therefore, an increase in BMI can indicate that the client is gaining weight and responding well to the treatment plan.

A. Planning to give his Xbox console to his best friend. B. Stating that he wants to be with his peers more than with his parents. C. Telling his parents that he doesn't want to talk about the suicide attempt. D. Preferring to eat his meals while watching TV.

Correct Answer is C

Explanation

The correct answer(s) is/are:

C. Telling his parents that he doesn't want to talk about the suicide attempt.

Rationale:

Choice A: Planning to give his Xbox console to his best friend.

While giving away possessions can be a sign of hopelessness or detachment, in this case, it could also be interpreted as a gesture of closure or wanting to leave something meaningful behind for a loved one. It doesn't necessarily indicate ongoing suicidal intent.

Choice B: Stating that he wants to be with his peers more than with his parents.

This desire for social connection and autonomy is actually a positive sign in a post-suicidal attempt adolescent. It demonstrates a shift towards seeking support from outside the family unit and engaging with life beyond the immediate aftermath of the attempt.

Choice C: Telling his parents that he doesn't want to talk about the suicide attempt. This reluctance to discuss the attempt can be a red flag for several reasons:

Avoidance: Suppressing or avoiding thoughts and feelings related to the attempt can indicate a struggle to cope with the emotional trauma and potentially harboring lingering suicidal ideation.

Isolation: Withdrawing from open communication about the event can isolate the adolescent further, hindering the support system and potentially increasing the risk of reattempt.

Underlying distress: The inability to talk about the event may suggest unresolved emotional distress, unresolved conflicts, or ongoing stressors that could contribute to suicidal thoughts.

Therefore, while not wanting to talk doesn't definitively signify current suicidal intent, it warrants further exploration by the nurse to understand the underlying reasons behind the avoidance and ensure appropriate support and safety measures are in place.

Choice D: Preferring to eat his meals while watching TV.

This behavior is relatively neutral and doesn't directly suggest ongoing suicidal intent. While it might indicate depression or low motivation, it's not a specific indicator of suicide risk.

Conclusion:

Based on the rationale above, "telling his parents that he doesn't want to talk about the suicide attempt" (Choice C) is the most concerning behavior that suggests the adolescent might still have suicidal intent. It's crucial for the nurse to address this reluctance with empathy and understanding, exploring the underlying reasons and ensuring continued monitoring and support for the adolescent.

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A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an outpatient mental health clinic is caring for a client who has anorexia nervosa. The nurse is assessing the client during a follow-up visit.Which of the following findings indicate a therapeutic response to the treatment plan? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

Correct Answer is C

Explanation

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A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?

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