A client with end-stage alcoholic cirrhosis of the liver is hesitant to talk about the illness and the impending loss of life from their alcohol use disorder. Which action by the nurse can promote the client's ability to express their feelings?

Ask the client if they are in denial regarding the seriousness of their illness.

Be an active listener and use silence to facilitate communication.

Refer the client to the chaplain for religious counseling.

Inform the client that since it is too late to change, acceptance is inevitable.

Answer and Explanation

The Correct Answer is B

Using active listening techniques and providing a supportive and non-judgmental environment can promote the client's ability to express their feelings. Many clients facing end-stage illnesses, such as alcoholic cirrhosis, may experience a range of emotions and find it difficult to talk about their illness or impending loss of life. By being present, attentive, and using silence when appropriate, the nurse allows the client the space and time they need to process their thoughts and emotions and feel comfortable expressing their feelings when they are ready.

Incorrect:

Option A may come across as confrontational and judgmental, which can hinder the client's willingness to share their feelings.

Option C may be appropriate if the client requests spiritual or religious support, but it should not be assumed as the primary intervention for promoting emotional expression.

Option D can be seen as dismissive and insensitive to the client's emotional needs, and it may not be helpful in encouraging the client to open up about their feelings.

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Correct Answer is D

Explanation

Explanation: This response demonstrates the use of therapeutic communication, specifically offering the client an opportunity to express their feelings and concerns in a non-confrontational manner. By suggesting a private and quiet area to talk to, the nurse provides a safe and supportive environment for the client to explore and process their emotions. This approach can help the client feel heard, validated, and understood, which may reduce their need to act out or engage in argumentative behaviors to express their feelings.

The other responses are not as effective or therapeutic:

A. Threatening the client with seclusion is an aggressive approach and may escalate the client's behavior or cause them to feel cornered and defensive, leading to further acting out.

B. Telling the client they have to take medication to stop their behavior does not address the underlying issues that may be causing their behavior. It can also come across as dismissive of the client's feelings and concerns.

C. Saying "I don't know what set you off today but you have to get along with others" may be perceived as dismissive and does not offer the client an opportunity to express their emotions or address their concerns.

In summary, offering a private space to talk and explore the client's feelings in a non-judgmental and supportive manner is the most beneficial therapeutic response to help the adolescent client decrease acting out behaviors and promote positive communication and coping skills.

A. Prior to performing any intervention that requires touch, the nurse will ask permission. B. Have the client perform all care independently and without assistance. C. Have two nurses present at all times in which to perform all care and procedures. D. The nurse will perform a continuous assessment of the client's anxiety level. E. Have security present outside of the client's room to prevent anyone from coming in.

Correct Answer is ["A","D","E"]

Explanation

The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:

A. Prior to performing any intervention that requires touch, the nurse will ask permission.

This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.

D. The nurse will perform a continuous assessment of the client's anxiety level.

Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.

E. Have security present outside of the client's room to prevent anyone from coming in.

Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.

It is not appropriate to:

B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.

C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.

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A client with end-stage alcoholic cirrhosis of the liver is hesitant to talk about the illness and the impending loss of life from their alcohol use disorder. Which action by the nurse can promote the client's ability to express their feelings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior?

Correct Answer is D

Explanation

The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

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The nurse is meeting with a client who is experiencing complicated grieving from the death of their child to suicide. In order to establish a therapeutic nurse-client relationship, what will the nurse do prior to the meeting?

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