A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress.
Which of the following statements by the nurse is appropriate?
"I will help you sit up and get your slippers on."
"If you do not get out of bed, you will not receive your meal."
"You should rest in bed until you feel able to take part in unit activities."
"You really need to follow the rules of the unit and get out of bed.".
The Correct Answer is A
This statement shows empathy and support for the client.
It also encourages the client to engage in self-care activities and promotes independence.
Choice B is not appropriate because it is a threat and does not show empathy or support for the client.
Choice C is not appropriate because it encourages the client to remain passive and does not promote independence.
Choice D is not appropriate because it is confrontational and does not show empathy or support for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“6 weeks after fertilization.” Teratogens can begin affecting the developing embryo as early as 10 to 14 days after conception 1.
During embryonic development, there are periods when the developing organ systems show more sensitivity to teratogens.
Choice A is incorrect because 18 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice C is incorrect because 12 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice D is incorrect because this is not an incomplete question/stem.
Correct Answer is C
Explanation
Choice A reason:
Placing traction weights so they touch the head of the bed disrupts the effectiveness of the traction system. Skeletal traction relies on a continuous pulling force to maintain proper alignment of the fractured femur. If the weights are resting on any surface, the force is interrupted, which can lead to complications such as malunion or delayed healing. The weights must hang freely at all times to ensure therapeutic benefit.
Choice B reason:
Isometric exercises are beneficial for maintaining muscle tone and promoting circulation during immobilization. However, while this is a supportive intervention, it is not the most critical or immediate nursing action in the context of skeletal traction. Encouraging exercises every 8 hours is appropriate, but it does not directly address the most urgent or discomfort-related aspect of care.
Choice C reason:
Pin care is a routine but potentially painful procedure associated with skeletal traction. Administering pain medication beforehand is a priority nursing action because it ensures client comfort, reduces anxiety, and promotes cooperation during the procedure. This intervention reflects both compassionate care and adherence to best practices in pain management and infection prevention.
Choice D reason:
Repositioning a client in skeletal traction must be done with extreme caution to avoid disrupting the traction setup. Assisting the client to shift position every 4 hours may inadvertently alter the alignment or tension of the traction apparatus. While pressure injury prevention is important, repositioning must be coordinated carefully and is not the most appropriate standalone action in this context.
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