A client with carotid stenosis has just discussed an upcoming surgery with the physician. The client tells the Practical Nurse (PN), “I wonder if I should let him cut my neck open?” Which nursing response is best?
"There is no reason to worry. This surgeon has an excellent reputation.”
“It sounds as though you have mixed feelings about the surgery. Can you tell me more about how you feel?”
"The benefits outweigh the risks. You can be confident that the surgery should be done.”
"You are bound to feel much beter once it is all over with.”
The Correct Answer is B
Choice A reason: "There is no reason to worry. This surgeon has an excellent reputation.” is not the best nursing response. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows authority, which is a communication barrier that involves using one’s position or status to influence or persuade the other person. It does not address the client’s emotions or needs, and may sound patronizing or condescending. Therefore, this choice is incorrect.
Choice B reason: “It sounds as though you have mixed feelings about the surgery. Can you tell me more about how you feel?” is the best nursing response. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.
Choice C reason: "The benefits outweigh the risks. You can be confident that the surgery should be done.” is not the best nursing response. This response shows persuasion, which is a communication technique that involves using logic or evidence to convince or influence the other person. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It does not address the client’s emotions or needs, and may sound coercive or manipulative. Therefore, this choice is incorrect.
Choice D reason: "You are bound to feel much beter once it is all over with.” is not the best nursing response. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also shows avoidance, which is a communication barrier that involves shifting the focus away from the other person’s feelings or situation. It does not address the client’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.
Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.
Choice C reason: Signs of fluid overload are objective data that indicate excess fluid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,
kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of fluid overload, but signs of fluid deficit or heat stroke. Therefore, this choice is incorrect.
Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.
Correct Answer is ["A"]
Explanation
Choice A reason: This is correct because it shows that the nurse is engaged and focused on the patient. Leaning slightly forward indicates that the nurse is listening and caring.
Choice B reason: This is correct because it shows that the nurse is open and receptive to the patient’s feelings and concerns. An open posture means that the nurse does not cross arms or legs, which can be seen as defensive or closed.
Choice C reason: This is incorrect because it shows that the nurse is distant and distracted from the patient. Standing at the doorway implies that the nurse is ready to leave or has other priorities. Reading the chart while smiling may seem insincere or superficial.
Choice D reason: This is correct because it shows that the nurse is respectful and atentive to the patient. Sitting at the bedside and facing the patient indicates that the nurse is giving eye contact and acknowledging the patient’s
presence.
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