A client who is having 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."
"Why would you say such a thing?"
"Well, that's your opinion."
"Tell me more about that."
The Correct Answer is D
Choice A Reason: This choice is incorrect because it reflects the nurse's feelings rather than focusing on the client's needs. Saying "That's a hurtful thing to say" may make the client feel guilty or defensive, and it does not address the underlying cause of the client's anger or frustration.
Choice B Reason: This choice is incorrect because it sounds accusatory and confrontational rather than empathetic and supportive. Asking "Why would you say such a thing?" may make the client feel judged or criticized, and it does not explore the client's feelings or concerns.
Choice C Reason: This choice is incorrect because it dismisses the client's feelings rather than acknowledging them. Saying "Well, that's your opinion" may make the client feel ignored or invalidated, and it does not show respect or compassion for the client.
Choice D Reason: This choice is correct because it invites the client to express their feelings and concerns rather than shutting them down. Saying "Tell me more about that" may make the client feel heard and understood, and it may help to identify the source of their anger or frustration. The nurse can then use therapeutic communication skills such as active listening, reflecting, clarifying, or validating to establish rapport and trust with the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This choice is correct because respiratory acidosis is a condition in which the lungs cannot eliminate enough carbon dioxide (CO2) from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A normal PaCO2 range is 35 to 45 mm Hg, so a value of 50 mm Hg indicates respiratory acidosis.
Choice B Reason: This choice is incorrect because HCO3 (bicarbonate) is a base that helps to buffer the excess acid in the blood. In respiratory acidosis, the kidneys try to compensate by retaining more HCO3 and excreting more hydrogen ions. Therefore, a high level of HCO3 (above 26 mEq/L) would indicate a chronic or compensated respiratory acidosis, not an acute or uncompensated one.
Choice C Reason: This choice is incorrect because pH is a measure of the acidity or alkalinity of the blood. A normal pH range is 7.35 to 7.45, so a value of 7.45 indicates a neutral or slightly alkaline blood, not an acidic one. A low pH (below 7.35) would indicate respiratory acidosis.
Choice D Reason: This choice is incorrect because potassium is an electrolyte that helps to regulate the nerve and muscle function, as well as the fluid balance in the body. In respiratory acidosis, the increased hydrogen ions in the blood may shift into the cells in exchange for potassium, resulting in a high level of potassium (hyperkalemia).
Therefore, a low level of potassium (below 3.5 mEq/L) would indicate hypokalemia, not respiratory acidosis.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because crepitus in the area above and surrounding the insertion site is not a serious finding that requires notification of the provider. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It is usually harmless and resolves on its own.
Choice B reason: This is incorrect because bubbling of the water in the water seal chamber with exhalation is a normal finding that indicates that air is being removed from the pleural space. Bubbling should stop when the pneumothorax is resolved.
Choice C Reason: This is incorrect because eyelets are not visible is not a serious finding that requires notification of the provider. Eyelets are small holes at the end of the chest tube that allow air and fluid to drain from the pleural space. They are usually covered by a dressing and may not be visible.
Choice D Reason: This is correct because movement of the trachea toward the unaffected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.
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