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 C
Explanation
Discarding the toothbrush and buying another is a way to prevent disease transmission, as the toothbrush can harbor bacteria and reinfect the child or spread the infection to others. The toothbrush should be discarded after 24 hours of antibiotic therapy.
a) Encouraging the child to drink lots of fluids is a way to promote hydration and soothe the throat, but it does not prevent disease transmission. The child should avoid sharing cups or utensils with others and use disposable tissues or paper towels.
b) Taking the child's temperature every 4 hours is a way to monitor fever, but it does not prevent disease transmission. The thermometer should be cleaned and disinfected after each use and not shared with others.
d) Giving the child Tylenol for the pain is a way to relieve discomfort, but it does not prevent disease transmission. The medication should be administered according to the label instructions and not shared with others.
Correct Answer is C
Explanation
Increased anteroposterior diameter of the chest, also known as barrel chest, is a common finding in clients who have COPD with emphysema. It is caused by chronic air trapping and hyperinflation of the lungs, which results in fattening of the diaphragm and widening of the rib cage.
a) Oxygen saturation level 96% is within the normal range of 95% to 100% and does not indicate hypoxemia or impaired gas exchange. Clients who have COPD with emphysema typically have lower oxygen saturation levels, ranging from 88% to 92%.
b) Respiratory alkalosis is a condition in which the blood pH is elevated due to decreased carbon dioxide levels. It is caused by hyperventilation, which can occur in response to hypoxia, anxiety, or pain. Clients who have COPD with emphysema usually have respiratory acidosis, which is a condition in which the blood pH is lowered due to increased carbon dioxide levels. It is caused by hypoventilation, which results from impaired lung function and airway obstruction.
d) Petechiae on chest are small red or purple spots on the skin caused by bleeding from capillaries. They are not a typical finding in clients who have COPD with emphysema, unless they have severe coughing episodes or coagulation disorders. They can indicate infection, inflammation, trauma, or vascular disease.
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