A client's father has recently died. Which response from the nurse would be most therapeutic?
‘I know how you feel. I've lost people close to me too."
"Your mother is still living to give you support."
"You will never be the same. This will make you stronger"
1 am sad for you. I'll stay with you for a while if you need to talk."
The Correct Answer is D
D. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.
A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.
B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.
C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
Correct Answer is ["1705"]
Explanation
To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.
First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.
Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.
Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.
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