A nurse in a clinic is collecting data from a client. The client reports that they do not believe in receiving immunizations. Which of the following questions should the nurse ask the client?
What makes you believe that the science behind immunization is wrong
Is not taking the immunization worth the risk of getting very sick during flu season
"Why a you opposed to receiving immunization
what your biggest concern with receiving immunization
The Correct Answer is D
A) "What makes you believe that the science behind immunization is wrong?": This question may come across as confrontational and judgmental, which can potentially shut down communication. It could make the client feel defensive and less likely to engage in an open discussion about their concerns. The nurse should aim to create a non-judgmental and open dialogue to understand the client's perspective.
B) "Is not taking the immunization worth the risk of getting very sick during flu season?": This question is somewhat leading and may sound as if the nurse is trying to pressure the client into changing their mind. It could also create a sense of guilt or fear rather than fostering a cooperative conversation about the client's beliefs and concerns.
C) "Why are you opposed to receiving immunization?": While this question may seem straightforward, it is a bit too direct and could feel accusatory to the client. It might be better to approach the conversation in a way that invites the client to express their concerns without feeling challenged or defensive.
D) "What is your biggest concern with receiving immunization?": This is the most effective and open-ended question. It allows the client to express their concerns in a non-confrontational way. The nurse can then listen to the client's reasons, provide information, and address any misconceptions or fears the client may have, fostering a respectful and informative discussion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Too many choices can be overwhelming and lead to increased frustration or "decision fatigue" for a confused client.
B) Delirium is characterized by an acute, fluctuating change in mental status. Reorientation helps anchor the client to reality and can reduce the anxiety or agitation associated with cognitive clouding.
C) Ignoring a client's fears can increase their sense of isolation and paranoia. Acknowledging feelings while gently correcting misconceptions is more therapeutic.
D) Consistency is key. Frequent changes in staff increase confusion; it is better to have the same nursing team to build familiarity.
Correct Answer is D
Explanation
A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.
B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.
C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.
D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.
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