A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
"Perhaps you should discuss this with your physician."
"Of course, you aren't going to die, at least not in the immediate future."
"I recommend you exercise daily and avoid smoking to decrease your risk."
"Tell me more about these fears of dying from a heart attack.".
The Correct Answer is D
Choice A rationale:
Deflecting the client's concerns to the physician dismisses the client's immediate need for emotional support and therapeutic communication.
It can hinder the development of a trusting nurse-client relationship.
The nurse is responsible for addressing the client's psychosocial needs, not solely deferring them to other healthcare professionals.
Choice B rationale:
Offering false reassurance is inappropriate and potentially harmful. It can erode trust if the client's fears are later realized.
It minimizes the client's legitimate concerns and invalidates their emotional experience.
Choice C rationale:
While lifestyle modifications are essential for managing coronary artery disease, providing unsolicited advice at this moment disregards the client's emotional distress.
It prioritizes physical health over the client's psychological well-being. It can be perceived as dismissive of the client's fears and concerns.
Choice D rationale:
Inviting the client to elaborate on their fears demonstrates active listening and encourages therapeutic communication. It validates the client's concerns and shows empathy for their emotional experience.
It provides an opportunity to assess the client's understanding of their condition and identify specific fears or misconceptions. It establishes a foundation for exploring coping mechanisms and providing appropriate support and education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale: Providing privacy when friends visit is a general good practice in nursing. However, it may not be the most effective intervention for a client with anorexia nervosa. Anorexia nervosa is characterized by a distorted body image and an intense fear of gaining weight. While privacy is important, it is not directly related to the management of anorexia nervosa.
Choice B rationale: Scheduling regular weigh-in times is a key intervention for clients with anorexia nervosa. Regular weigh-ins help monitor the client’s progress and any potential complications related to weight loss. This intervention is directly related to the management of anorexia nervosa and is therefore the correct answer.
Choice C rationale: Complimenting the client for weight gain can be a sensitive issue for individuals with anorexia nervosa. While it might seem like a positive reinforcement, it could potentially trigger anxiety and fear in the client, as individuals with anorexia nervosa have an intense fear of gaining weight. Therefore, this intervention should be handled with care and is not the best choice in this scenario.
Choice D rationale: Allowing the client to eat at any time might seem like a good idea, but it is not the most effective intervention for a client with anorexia nervosa. Individuals with anorexia nervosa often have strict rituals and rules around eating. Allowing them to eat at any time might not address these underlying issues and could potentially enable their disordered eating habits.
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