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 D
Explanation
Choice A reason:
Calling the lab to verify the client’s results is a reasonable step if there is any doubt about the accuracy of the lab results. However, in this scenario, the potassium level of 5.2 mEq/L is already documented, and the nurse should act on this information. Verifying the results would delay necessary actions and could potentially harm the patient if the high potassium level is not addressed promptly.
Choice B reason:
Omitting the KCL dose and documenting it as not given is a prudent action because administering potassium chloride to a patient with an elevated potassium level (5.2 mEq/L) could exacerbate hyperkalemia, which can lead to serious cardiac issues. However, this action alone is not sufficient. The nurse must also inform the prescribing physician to reassess the patient’s treatment plan.
Choice C reason:
Giving the ordered KCL as prescribed would be inappropriate in this situation. The patient’s potassium level is already elevated, and administering additional potassium could lead to hyperkalemia, which can cause dangerous cardiac arrhythmias or even cardiac arrest. Therefore, this option should be avoided.
Choice D reason:
Calling the prescribing physician and informing her of the client’s serum potassium level results is the most appropriate action. The physician needs to be aware of the elevated potassium level to make an informed decision about the patient’s treatment plan. The physician may decide to withhold the potassium chloride, order additional tests, or take other actions to manage the patient’s potassium levels safely.
Correct Answer is D
Explanation
Choice A reason: Implement a resolution
Implementing a resolution without first understanding the root cause of the conflict can lead to ineffective solutions and may not address the underlying issues. It is essential to identify the problem first to ensure that any resolution is appropriate and effective.
Choice B reason: Evaluate the results
Evaluating the results is an important step in the conflict resolution process, but it comes after implementing a solution. Before any evaluation can take place, the problem must be identified, and a resolution must be implemented. Therefore, this step is not the first action to take.
Choice C reason: Brainstorm solutions
Brainstorming solutions is a critical part of resolving conflicts, but it should occur after the problem has been clearly identified. Without a clear understanding of the problem, brainstorming may not yield effective solutions. Identifying the problem ensures that the brainstorming session is focused and productive.
Choice D reason: Identify the problem
Identifying the problem is the first and most crucial step in resolving any conflict. Understanding the root cause of the conflict between the pharmacy and the staff nurses will provide a clear direction for developing effective solutions. This step involves gathering information, listening to all parties involved, and pinpointing the specific issues that need to be addressed.
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