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?".
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: Identify the required dose of lithium, which is 300 mg.
Step 2: Identify the available dose of lithium carbonate, which is 150 mg per capsule.
Step 3: Calculate the number of capsules needed using the formula: Number of capsules = Required dose ÷ Available dose.
Numberofcapsules=300 mg150 mg/capsule
\(Number\ of\ capsules = {300\ mg \over 150\ mg/capsule}\)
Step 4: Solve the equation.
Numberofcapsules=2 capsulesNumberofcapsules=2capsules
So, the nurse should administer 2 capsules per dose to achieve the required lithium dose of 300 mg.
Correct Answer is A
Explanation
Rationale:
A. Agoraphobia: This choice directly aligns with the client's presentation of being afraid to leave her home alone. Agoraphobia is a specific phobia characterized by an intense fear of situations that the individual perceives as inescapable or that might potentially lead to panic or embarrassment. Common triggers for agoraphobic individuals include crowded spaces, open spaces, public transportation, or being alone outside of the home. The client's inability to leave her home for weeks due to fear is a classic symptom of agoraphobia.
B. Xenophobia: This choice refers to the fear of strangers or foreigners. While the client may experience anxiety in unfamiliar situations, the primary focus of her fear is being outdoors alone rather than encountering unfamiliar people. Additionally, the daughter's description of the client's fear specifically mentions being alone, further supporting agoraphobia as the more likely diagnosis.
C. Mysophobia: This choice refers to an extreme or obsessive fear of germs or contamination. While anxiety related to cleanliness could coexist with agoraphobia, the primary presenting complaint in this case is the fear of being outdoors, not specifically germs or contamination.
D. Aerophobia: This choice refers to the fear of flying or being in high places. There is no indication in the scenario that the client's fear is specifically related to heights or flying, making this choice less likely.
Therefore, based on the specific nature of the client's fear and the limited information provided, agoraphobia is the most probable diagnosis and the one the nurse should anticipate planning care for.
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