A nurse is caring for a client who has recently retired from their job. The client states they feel like they no longer have a purpose. Which of the following responses should the nurse make?

"Can you tell me what you mean by not having any purpose?"

"Have you started volunteering in the community?"

"You must plan to get involved in some new hobbies."

"You seem in good health and able to handle whatever life presents."

Answer and Explanation

The Correct Answer is A

A. This response is appropriate because it shows empathy, respect, and interest in the client's feelings and thoughts. It also invites the client to explore and clarify their meaning of purpose and how it relates to their retirement.
B. This response is dismissive of the client’s concern.

C. While hobbies can be fulfilling, this response does not address the client's feelings of purposelessness directly.
D. This response minimizes the client's feelings and does not offer constructive solutions to address their concerns.

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Correct Answer is B

Explanation

A. Extracellular fluid volume deficit (dehydration) typically leads to decreased venous return and reduced preload, resulting in flat or collapsed neck veins, rather than distended ones.
B. In extracellular fluid volume deficit, there is a decrease in blood volume, which can result in postural hypotension when the client changes positions, due to inadequate fluid volume to maintain blood pressure.
C. Extracellular fluid volume deficit is characterized by decreased fluid volume, which leads to decreased tissue perfusion and fluid shifts out of the interstitial spaces, resulting in reduced or absent edema.
D. Bradycardia is not typically associated with extracellular fluid volume deficit.

Instead, tachycardia may occur as a compensatory mechanism to maintain cardiac output in response to decreased blood volume.

A. Place their arms around the client to prevent the fall. B. Remain upright as the client fails toward them. C. Move quickly to a position in front of the client. D. Allow the client to slide down their outstretched leg.

Correct Answer is D

Explanation

A. This action may increase the risk of injury to both the nurse and the client.

B. This action does not effectively prevent the fall or minimize injury.

C. Moving quickly to a position in front of the client can cause imbalance and increase the risk for falling.
D. Allowing the client to slide down their outstretched leg can help prevent injury to both the client and the nurse.

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A nurse is caring for a client who has recently retired from their job. The client states they feel like they no longer have a purpose. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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