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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Applying lubricant to the cannula tubing is not the best intervention as it may cause irritation or infection of the nasal mucosa. The nurse should use water-soluble gel or saline spray to moisten the nasal passages if needed.

Choice B reason: Placing padding around the cannula tubing is the best intervention as it prevents friction and pressure on the skin. The nurse should use soft materials such as gauze or foam to cushion the tubing and check the skin integrity frequently.

Choice C reason: Decreasing the flow rate to 1 L/minute is not an appropriate intervention as it may compromise the client's oxygenation. The nurse should maintain the prescribed flow rate and monitor the client's vital signs and oxygen saturation.

Choice D reason: Discontinuing the use of the nasal cannula is not an option as it may endanger the client's life. The nurse should continue the oxygen therapy as ordered and provide comfort measures and education to the client.

A. "Tell me about the visit with your significant other." B. "Would you like to talk for a little while?" C. "What did you enjoy about your visit tonight?" D. "I can see that you are feeling lonely."

Correct Answer is B

Explanation

Choice A reason:This directive approach may pressure the client to discuss details they are not ready to share, potentially causing discomfort.

Choice B reason:This open-ended offer demonstrates the nurse's availability and support, allowing the client to decide whether to engage in conversation, thereby respecting their autonomy.

Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

Correct Answer is B

Explanation

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

Correct Answer is B

Explanation

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