A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?
Explain that alternative treatment options may be helpful.
Remind the spouse that the client may still live a long time.
Offer reassurance that the spouse is not alone.
Encourage the spouse to share their feelings.
The Correct Answer is C
C. The first action the nurse should take is to offer reassurance to the spouse that they are not alone. This statement acknowledges the spouse's emotional distress and provides comfort and support during a difficult time. It also validates the spouse's feelings of loneliness and acknowledges the importance of their presence and support for the client.
A and B focus on the client's illness or prognosis, which may not be the immediate concern for the spouse at this moment.
D, while valuable, may come after the initial reassurance to create a supportive environment for the spouse to share their feelings when they feel ready.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. When a client is observed using accessory muscles, it suggests increased effort in breathing, which may indicate respiratory distress or compromise. Therefore, the first vital sign the nurse should obtain is the respiratory rate to assess the client's breathing pattern and adequacy of ventilation.
A, B and D are important vitals signs in all clients. However, respiratory rate is of more concern in a client with signs of respiratory distress (use of accessory muscles).
Correct Answer is C
Explanation
C. The first action the nurse should take is to offer reassurance to the spouse that they are not alone. This statement acknowledges the spouse's emotional distress and provides comfort and support during a difficult time. It also validates the spouse's feelings of loneliness and acknowledges the importance of their presence and support for the client.
A and B focus on the client's illness or prognosis, which may not be the immediate concern for the spouse at this moment.
D, while valuable, may come after the initial reassurance to create a supportive environment for the spouse to share their feelings when they feel ready.
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