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 B
Explanation
Identifying appropriate placement for infectious clients requires understanding transmission-based precautions. Tuberculosis is an airborne pathogen requiring specialized ventilation to prevent the spread of droplet nuclei. Knowledge of negative pressure systems and environmental safety standards is essential for preventing nosocomial transmission to others.
Choice A rationale
Placing a client with active tuberculosis in a semi-private room violates airborne precautions. This increases the risk of horizontal transmission to immunocompromised roommates via microscopic droplet nuclei that remain suspended in the air for several hours.
Choice B rationale
Airborne infection isolation rooms require a minimum of 6 to 12 air exchanges per hour. Exhausting air directly outdoors or through HEPA filters prevents contaminated air from recirculating into common hallways or other patient care areas.
Choice C rationale
Admission to an intensive care unit is reserved for hemodynamically unstable clients or those requiring advanced mechanical ventilation. Tuberculosis alone is not an indication for critical care unless the client exhibits acute respiratory failure or septic shock.
Choice D rationale
While proximity to the nurses' station allows for frequent observation, it does not address the physiological requirement for negative pressure ventilation. Standard medical-surgical rooms lack the engineering controls necessary to contain airborne bacilli within the specific room.
Correct Answer is D
Explanation
This case focuses on managing urolithiasis with signs of potential urinary obstruction. Knowledge of the nursing process, prioritization of physiological needs, and the distinction between pain management and critical organ perfusion/output is necessary to determine the first action.
Choice A rationale
Straining urine is important for stone analysis but is not the immediate priority for a client who hasn't voided in 6 hours. Assessment of the underlying cause of urinary retention must occur before focusing on stone recovery procedures.
Choice B rationale
Encouraging fluids helps flush stones but may exacerbate pain or vomiting if a total obstruction is present. The client's lack of output for 6 hours requires an assessment of bladder status before increasing fluid load significantly.
Choice C rationale
Pain management is essential for urolithiasis, but the lack of urinary output is a physiological priority. Assessing for bladder distention or obstruction ensures the kidneys are not sustaining damage from hydronephrosis before focusing solely on symptomatic relief.
Choice D rationale
Assessing for bladder distention is the priority to determine if the client is experiencing urinary retention due to obstruction. Identifying whether urine is being produced but trapped in the bladder is critical for preventing renal injury and hydronephrosis..
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.