A nurse is caring for a client who has acute lymphocytic leukemia. The client is refusing blood products. Which one of the following responses should the nurse take?
“I understand that you decided not to receive blood products.”
“Not receiving blood will slow down your memory”
“Why are you refusing to receive blood products?”
“You need to talk with your doctor about this”
The Correct Answer is A
Choice A Reason:
“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.
Choice B Reason:
“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.
Choice C Reason:
“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.
Choice D Reason:
“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Setting the maximum water heater temperature to 54.4° C (130° F) is appropriate. This temperature is too high and could pose a burn risk, especially for someone with impaired vision who might not easily detect very hot water.
Choice B Reason:
Painting the edges of steps for contrast is appropriate. This measure helps increase visibility by creating a visual contrast between the edges of steps and the surrounding area, aiding the individual in identifying the steps more easily, even with reduced vision.
Choice C Reason:
Securing extension cords across walkways is inappropriate. Placing extension cords across walkways can create tripping hazards, particularly for someone with vision loss who may have difficulty seeing these obstacles.
Choice D Reason:
Using 40-watt bulbs to light hallways is inappropriate. While adequate lighting is crucial for individuals with vision impairment, using only 40-watt bulbs might not provide sufficient illumination. It's recommended to use higher-wattage bulbs or brighter lighting sources to ensure better visibility in the home.
Correct Answer is C
Explanation
Choice A Reason:
"Opioids will be restricted if your partner develops respiratory distress." This statement might cause unnecessary concern or confusion. While opioid use might be adjusted based on the client's condition and symptoms, framing it in terms of restriction might not be the most appropriate way to communicate about pain management in end-of-life care.
Choice B Reason:
"Encourage your partner to eat three large meals each day." Encouraging large meals might not align with the typical dietary approach for someone in end-of-life care, especially if they have reduced appetite or are unable to eat comfortably. End-of-life care often focuses on providing smaller, more manageable meals based on the individual's preferences and capabilities.
Choice C Reason:
"Assume your partner can hear you, even if they do not respond. “This statement encourages the partner to communicate with their loved one, acknowledging the potential for the person to hear even if they are not responsive. Many studies suggest that hearing may persist even in individuals who are unresponsive or in a comatose state, so speaking to them can provide comfort and connection.
Choice D Reason:
"We will use an electric blanket to keep your partner warm." The use of an electric blanket might not be suitable, as the client's sensitivity to temperature might change in end-of-life care. Other methods, such as blankets or adjusting the room temperature, could be more appropriate to ensure comfort without the risks associated with electric blankets.
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