A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die."
Which of the following responses should the nurse make?
"I'm sure your family does not want you to die."
"Why would you believe such things?"
"How does this make you feel?"
"You should talk to your family about your feelings."
The Correct Answer is C
"How does this make you feel?"
- A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
- B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
- C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
- D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Instructing the client to "Lie down for 30 min after meals" is an inappropriate recommendation for managing heartburn during pregnancy. Lying down after meals allows stomach acid from flowing back into the esophagus, worseningheartburn symptoms.
Choice B rationale:
Eating a high-fat snack at bedtime is not advisable for managing heartburn. Fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus and worsen heartburn symptoms. Avoiding high-fat snacks close to bedtime is a more appropriate recommendation.
Choice C rationale:
Sipping carbonated beverages throughout the day can exacerbate heartburn symptoms. Carbonated beverages, including sodas and sparkling water, can increase stomach acid and contribute to heartburn. Therefore, advising the client to avoid carbonated beverages is more appropriate for managing heartburn during pregnancy.
Choice D rationale:
Drinking hot herbal tea alleviates the heartburn symptoms and is recommended in pregnancy.
Correct Answer is B
Explanation
Choice A rationale:
While providing end-of-life education is important, it is not a specific requirement under the Patient Self-Determination Act. The act primarily focuses on ensuring that patients' wishes regarding medical treatment and interventions are respected through advance directives.
Choice B rationale:
Documenting in the client's medical record if the client has advance directives is a requirement under the Patient Self-Determination Act. This documentation ensures that healthcare providers are aware of the patient's preferences regarding medical treatment, especially in end-of-life situations. Advance directives may include living wills or durable power of attorney for healthcare, allowing patients to express their choices regarding medical interventions and appointing someone to make decisions on their behalf if they are unable to do so.
Choice C rationale:
Providing the client with a list of eligible individuals who can serve as a health care proxy is not a requirement under the Patient Self-Determination Act. While it can be helpful, the act primarily emphasizes documenting and respecting the patient's existing advance directives.
Choice D rationale:
Ensuring the client has an attorney for assistance with end-of-life documents is not a requirement under the Patient Self-Determination Act. While legal advice can be beneficial, the act primarily focuses on healthcare providers' responsibilities in documenting and respecting patients' advance directives.
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