A client's wife has just learned that her husband is terminally ill. She 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?
Offer reassurance that she is not alone.
Explain that alternative treatment options may be helpful.
Encourage the wife to share her feelings.
Remind her that her husband may still live a long time.
The Correct Answer is C
Choice A reason: Offering reassurance that she is not alone is not the best action to take first. It may sound dismissive of her feelings and make her feel more isolated.
Choice B reason: Explaining that alternative treatment options may be helpful is not the best action to take first. It may give false hope or imply that the wife is not accepting the reality of her husband's condition.
Choice C reason: Encouraging the wife to share her feelings is the best action to take first. It shows empathy and respect for her emotional state. It also allows the nurse to assess her coping skills and provide appropriate support.
Choice D reason: Reminding her that her husband may still live a long time is not the best action to take first. It may contradict the medical prognosis and make the wife feel more confused and anxious.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Positive external places are images of pleasant and relaxing environments that can distract the client from the pain and induce a sense of calmness and well-being. Examples of positive external places are a beach, a garden, or a mountain.
Choice B reason: Emotional reflection is a process of exploring and expressing one's feelings and emotions. It may be helpful for some clients to cope with stress and anxiety, but it is not the best focus for guided imagery for chronic pain. Emotional reflection may trigger negative emotions or memories that can worsen the pain perception.
Choice C reason: Motivational phrases are statements that encourage and inspire the client to achieve a goal or overcome a challenge. They may be useful for some clients to boost their self-confidence and self-efficacy, but they are not the best focus for guided imagery for chronic pain. Motivational phrases may not be effective in reducing the pain intensity or duration.
Choice D reason: Tranquil sounds are noises that create a soothing and peaceful atmosphere. They may be helpful for some clients to relax and fall asleep, but they are not the best focus for guided imagery for chronic pain. Tranquil sounds may not be enough to divert the client's attention from the pain or create a positive emotional state.

Correct Answer is D
Explanation
Choice A reason: Reviewing the chart for number of voids over the last 24 hours is not the best action to evaluate the client for urinary retention. It may provide some information about the client's urinary pattern, but it does not indicate the amount of urine left in the bladder after voiding.
Choice B reason: Palpating the suprapubic region for distention is a useful action to assess the client for urinary retention, but it is not the most accurate or reliable method. It may be difficult to palpate the bladder if the client is obese, has abdominal pain, or has bowel distention.
Choice C reason: Evaluating the client for urinary incontinence is not relevant to the assessment of urinary retention. Urinary incontinence is the involuntary loss of urine, while urinary retention is the inability to empty the bladder completely.
Choice D reason: Scanning the client's bladder after voiding is the best action to evaluate the client for urinary retention. It is a noninvasive and precise technique that measures the post-void residual urine volume. A normal post-void residual is less than 50 mL, while a high post-void residual indicates urinary retention.

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