A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
"Your doctor is a great surgeon. You will be fine."
"You may feel scared. Let's talk about what you are afraid of."
"I understand your fears. I was a smoker also."
"Don't worry. The important thing is you have now quit smoking."
The Correct Answer is B
This response is empathetic and therapeutic, as it acknowledges the client's feelings and invites her to express her concerns. It also shows respect and interest in the client's perspective.
a) This response is false reassurance and nontherapeutic, as it dismisses the client's feelings and implies
that the surgery will solve everything.
b) This response is self-disclosure and nontherapeutic, as it shifts the focus from the client to the nurse and
does not address the client's fears.
d) This response is minimizing and nontherapeutic, as it tells the client how to feel and does not acknowledge the client's regret or anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Performing the procedure independently is the best indicator of the partner's readiness for the client's discharge, as it demonstrates competence and confidence in suctioning. Suctioning is a skill that requires practice and supervision until mastery is achieved. The nurse should observe and evaluate the partner's performance of suctioning and provide feedback and reinforcement as needed.
b) Attending a class given about tracheostomy care is a good action by the partner, but not the best indicator of readiness for the client's discharge. Attending a class can provide information and education about tracheostomy care, but it does not necessarily translate into skill acquisition or application. The nurse should assess the partner's understanding and retention of the information and provide additional teaching or clarification as needed.
c) Verbalizing all steps in the procedure is a good action by the partner, but not the best indicator of readiness for the client's discharge. Verbalizing all steps in the procedure can help the partner remember and follow the correct sequence and technique of suctioning, but it does not necessarily reflect actual performance or ability. The nurse should observe and verify that the partner is doing what they are saying and correct any errors or omissions as needed.
d) Asking appropriate questions about suctioning is a good action by the partner, but not the best indicator of readiness for the client's discharge. Asking appropriate questions about suctioning can show interest and involvement in learning and caring for the client, but it does not necessarily indicate competence or confidence in suctioning. The nurse should answer the partner's questions and provide additional resources or referrals as needed.
Correct Answer is C
Explanation
Intercostal retractions, or the inward movement of the chest wall between the ribs, are a sign of respiratory distress and hypoxia. They indicate increased work of breathing and reduced lung expansion, which are common in clients who have postoperative atelectasis. Atelectasis is a collapse of alveoli in a part of the lung, which impairs gas exchange and oxygenation.
a) Lethargy, or a state of reduced mental alertness and energy, is not a typical manifestation of hypoxia. It can be caused by other factors, such as pain, medication, infection, or electrolyte imbalance. Hypoxia usually causes restlessness, anxiety, or confusion.
b) Bradycardia, or a slow heart rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, vagal stimulation, or heart block. Hypoxia usually causes tachycardia, or a fast heart rate, as the body tries to compensate for the low oxygen level.
d) Bradypnea, or a slow respiratory rate, is not a typical manifestation of hypoxia. It can be caused by other factors, such as medication, brain injury, or metabolic alkalosis. Hypoxia usually causes tachypnea, or a fast respiratory rate, as the body tries to increase oxygen intake and carbon dioxide elimination.
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