A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?
If you continue to refuse to eat, I will have to insert an NG tube
Why aren't you willing to eat?
"Your nutrition is more important than your beliefs.
Let's discuss some menu options you would be interested in."
The Correct Answer is D
A) If you continue to refuse to eat, I will have to insert an NG tube: This response is coercive and may not be respectful of the client’s autonomy. It can create a sense of fear and mistrust, which can make the client feel pressured or cornered. It is important to respect the client’s beliefs and preferences while also promoting nutrition, so alternative options should be explored in a more collaborative manner.
B) Why aren't you willing to eat?: While it’s important to understand the client’s reasons for refusing to eat, this response could come across as confrontational. It may place the client on the defensive and fail to acknowledge their beliefs and autonomy. A more open-ended and supportive approach is needed to create a dialogue that is respectful and patient-centered.
C) "Your nutrition is more important than your beliefs.": This response disregards the client's personal beliefs and could be perceived as disrespectful. While nutrition is critical, it is important to work within the framework of the client’s values and beliefs. The nurse should strive for a compassionate conversation that balances nutritional needs with cultural or personal beliefs.
D) Let's discuss some menu options you would be interested in.: This response is respectful of the client’s beliefs and autonomy while still addressing the issue of malnutrition. By offering options and engaging the client in the decision-making process, the nurse fosters a collaborative approach. This can help increase the likelihood of the client agreeing to eat while respecting their preferences and beliefs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Steatotic liver disease: Steatotic liver disease, or fatty liver disease, is typically associated with excess fat in the liver, often linked to alcohol use, obesity, or diabetes. While it can affect liver function, it is not primarily associated with deficiencies in iron and vitamin B12. Therefore, this condition is not directly related to the lab findings of low iron and vitamin B12.
B) Leukemia: Leukemia is a type of cancer that affects the blood and bone marrow, leading to abnormal white blood cell production. While leukemia can cause anemia as a secondary effect due to bone marrow dysfunction, it is not typically characterized by deficiencies in both iron and vitamin B12 simultaneously. The lab findings are more consistent with a nutritional or absorption issue rather than leukemia.
C) Hepatitis: Hepatitis refers to inflammation of the liver, usually caused by a viral infection or other factors. While hepatitis can lead to various blood abnormalities, it is not specifically linked to both iron and vitamin B12 deficiencies. Hepatitis more commonly affects liver function and may cause jaundice, but it does not directly explain low iron and B12 levels.
D) Anemia: Both iron and vitamin B12 are essential for the production of healthy red blood cells. Iron deficiency can lead to iron-deficiency anemia, and vitamin B12 deficiency can cause pernicious anemia. Therefore, low levels of both iron and vitamin B12 suggest the possibility of anemia, and the nurse should monitor the client for signs and symptoms of this condition, such as fatigue, pallor, and weakness.
Correct Answer is ["A","B","E","F"]
Explanation
A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.
B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.
C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.
D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.
E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.
F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.
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