A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?
It doesn’t appear as though you are feeling anxious.
Tell me what has been happening lately.
I think you should see a therapist.
Do you think your anxiety is worse than everyone else’s?
The Correct Answer is B
Choice A reason:
Saying “It doesn’t appear as though you are feeling anxious” is not an appropriate response. This statement invalidates the client’s feelings and can make them feel misunderstood or dismissed. It is important for the nurse to acknowledge the client’s report of anxiety and provide a supportive environment for them to express their concerns.
Choice B reason:
“Tell me what has been happening lately” is the most appropriate response. This open-ended question encourages the client to share more about their experiences and feelings, which can help the nurse understand the underlying causes of the anxiety. It also shows empathy and a willingness to listen, which are crucial in building a therapeutic relationship.
Choice C reason:
“I think you should see a therapist” might be a helpful suggestion, but it is not the best immediate response. While referring the client to a therapist can be part of the long-term management plan, the nurse should first listen to the client’s concerns and provide immediate support. Suggesting therapy right away might make the client feel like their concerns are being brushed off.
Choice D reason:
“Do you think your anxiety is worse than everyone else’s?” is not a helpful response. This question can come across as judgmental and may make the client feel defensive or invalidated. It is important for the nurse to focus on understanding the client’s individual experience rather than comparing it to others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The statement “Muffled heart sounds” is a classic sign of cardiac tamponade. This condition occurs when fluid accumulates in the pericardium (the sac around the heart), compressing the heart and preventing it from functioning properly. Muffled heart sounds are due to the fluid dampening the sound of the heartbeats. This is part of Beck’s triad, which also includes hypotension and jugular venous distension.
Choice B reason:
The statement “Sudden lethargy” is not a specific indicator of cardiac tamponade. While lethargy can occur due to decreased cardiac output and poor perfusion, it is not a definitive sign of cardiac tamponade. Lethargy can be caused by various conditions and is not specific enough to support the suspicion of cardiac tamponade.
Choice C reason:
The statement “Flattened neck veins” is incorrect. In cardiac tamponade, one would expect to see distended (bulging) neck veins due to increased central venous pressure. Flattened neck veins are not consistent with the hemodynamic changes seen in cardiac tamponade.
Choice D reason:
The statement “Bradycardia” is not typically associated with cardiac tamponade. Instead, tachycardia (an increased heart rate) is more commonly seen as the body attempts to compensate for decreased cardiac output. Bradycardia can occur in severe cases or as a pre-terminal event, but it is not a primary indicator of cardiac tamponade.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A"}}
Explanation
Joint Pain
Sickle Cell Disease: Joint pain is a common symptom of sickle cell disease due to vaso-occlusive crises, where sickle- shaped red blood cells block blood flow to the joints, causing pain and inflammation. These episodes can be severe and recurrent, leading to chronic pain and joint damage over time.
Leukemia: Joint pain can also be a symptom of leukemia, particularly in children. This occurs because leukemia cells can infiltrate the bone marrow, causing bone and joint pain. The pain is often due to the expansion of the marrow cavity by the leukemic cells.
Heart Rate at 1000
Sickle Cell Disease: An increased heart rate (tachycardia) can occur in sickle cell disease due to anemia. The body compensates for the reduced oxygen-carrying capacity of the blood by increasing the heart rate.
Iron Deficiency Anemia: Tachycardia is also a common symptom of iron deficiency anemia. The heart works harder to pump more blood to deliver adequate oxygen to tissues, resulting in an increased heart rate.
Leukemia: In leukemia, anemia can develop due to the replacement of normal bone marrow cells with leukemic cells, leading to a reduced number of red blood cells and subsequent tachycardia as the body attempts to compensate.
Respiratory Status
Sickle Cell Disease: Dyspnea (difficulty breathing) and labored breathing can occur in sickle cell disease due to anemia and acute chest syndrome, a severe complication where sickle cells block blood flow in the lungs.
Iron Deficiency Anemia: Respiratory symptoms such as shortness of breath and labored breathing are common in iron deficiency anemia due to the reduced oxygen-carrying capacity of the blood.
Leukemia: Leukemia can cause respiratory symptoms due to anemia and the infiltration of leukemic cells into the lungs, leading to reduced oxygenation and labored breathing.
Jaundice
Sickle Cell Disease: Jaundice is a common symptom of sickle cell disease due to the increased breakdown of red blood cells (hemolysis), leading to elevated bilirubin levels.
Leukemia: Jaundice can also occur in leukemia if the liver is infiltrated by leukemic cells or if there is significant hemolysis.
Ankle Ulcer
Sickle Cell Disease: Ankle ulcers are a common complication of sickle cell disease. They result from poor blood flow and oxygen delivery to the skin, leading to chronic, non-healing ulcers.
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