A client who experienced a myocardial infarction tells the nurse that he is fearful of dying.
Which statement by the nurse will help validate this client's feelings?
"It must be very frightening to be told that you've had a heart attack.”.
"Why are you afraid? Can you explain your fear of dying?"
"Please be assured that we're doing everything possible to prevent you from dying.”.
"Facing death would certainly be a frightening experience for me.”.
The Correct Answer is A
This scenario requires the application of therapeutic communication principles, specifically validation. Validating feelings involves acknowledging the client's emotional state without dismissing it. Nurses must distinguish between open-ended exploration, false reassurance, and self-disclosure to effectively support patients experiencing acute psychological distress.
Choice A rationale
Validation occurs when the nurse acknowledges the client's subjective experience. Myocardial infarction triggers significant anxiety regarding mortality. Acknowledging that the situation is frightening provides empathy and validates the client's feelings without being dismissive or providing false reassurance.
Choice B rationale
Asking why is often perceived as accusatory and may put the client on the defensive. It requires the client to analyze their emotions logically during a crisis, which can block further therapeutic communication and effective emotional expression.
Choice C rationale
This statement provides false reassurance. In a clinical setting, nurses cannot guarantee specific outcomes. This approach shuts down the client's expression of fear by shifting the focus to clinical actions rather than acknowledging the emotional reality.
Choice D rationale
This is an example of self-disclosure. By focusing on the nurse's own hypothetical feelings, the conversation shifts away from the client. Therapeutic communication must remain client-centered rather than focusing on the nurse's personal perspectives or reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
Diagnosing acute pancreatitis involves analyzing inflammatory markers, pancreatic enzymes, and metabolic changes. Knowledge of systemic inflammatory response syndrome and the endocrine/exocrine functions of the pancreas is necessary to identify labs indicating tissue necrosis, inflammation, and secondary metabolic disturbances.
Choice A rationale
Pancreatitis triggers a systemic inflammatory response, leading to leukocytosis. An elevated white blood cell count (normal range 5,000 to 10,000 cells/mm) is a common finding indicating active inflammation or secondary infection within the pancreatic tissue.
Choice B rationale
In acute pancreatitis, hematocrit often increases rather than decreases due to hemoconcentration. Fluid shifts from the intravascular space into the peritoneal cavity (third spacing) cause a relative rise in hematocrit, indicating significant volume depletion.
Choice C rationale
Serum amylase (normal range 30 to 110 U/L) typically increases rapidly within hours of symptom onset in pancreatitis. A decreased level is not supportive of this diagnosis; levels usually rise three times the upper limit.
Choice D rationale
Serum lipase (normal range 0 to 160 U/L) is a highly specific marker for pancreatic damage. In acute pancreatitis, lipase levels rise significantly and remain elevated longer than amylase, making it a primary diagnostic indicator.
Choice E rationale
Hypertriglyceridemia is both a cause and a result of acute pancreatitis. Serum triglycerides exceeding 1,000 mg/dL can precipitate an attack. Elevated levels support the diagnosis and help identify the potential underlying metabolic etiology.
Choice F rationale
The pancreas produces insulin via islets of Langerhans. Inflammation impairs endocrine function, leading to hyperglycemia (normal fasting glucose 70 to 99 mg/dL). Elevated glucose is a common secondary finding in acute pancreatic injury.
Correct Answer is C
Explanation
Postoperative care for cardiac surgery requires balancing pain management with respiratory function. Knowledge of pulmonary mechanics and the risks of atelectasis is necessary to identify how analgesia facilitates deep breathing and coughing to prevent pneumonia and improve oxygenation.
Choice A rationale
Opioids can cause vasodilation and subsequent hypotension, but reducing blood pressure is not the therapeutic goal of analgesia in this context. While beneficial for cardiac workload, it is not the most critical recovery factor here.
Choice B rationale
Anxiety reduction is a secondary benefit of pain control that improves patient comfort. However, physiological stabilization and the prevention of respiratory complications take precedence over psychological comfort in the immediate postoperative phase after a bypass.
Choice C rationale
Postoperative pain causes guarded, shallow respirations, increasing the risk of lung collapse. Effective analgesia allows the client to perform deep breathing and incentive spirometry, which are vital for maintaining alveolar expansion and preventing secondary infections.
Choice D rationale
Sleep is necessary for cellular repair and overall recovery. While opioids help a patient rest, the primary physiological priority for a bypass patient is maintaining adequate gas exchange through effective ventilation, which requires active respiratory effort.
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