A nurse is caring for a client who is about to undergo open-heart surgery. The client states that he is very nervous about the surgery. Which of the following responses should the nurse make?

Give the client some reading material about their upcoming surgery to help ease their mind.

Suggest that the client take a walk around the unit.

Refer the client to the pastoral care team.

Speak with the client and ask him to describe what they are feeling.

Answer and Explanation

The Correct Answer is D

Choice A reason:
Providing reading material about the surgery can be informative, but it may not be the best approach for someone who is already very nervous. It could potentially increase anxiety if the information is overwhelming or if the client misinterprets the material.

Choice B reason:
Suggesting a walk could serve as a distraction and help to calm the client's nerves. However, it might not address the underlying anxiety about the surgery itself. It's a temporary measure that doesn't offer emotional support or address the client's immediate concerns.

Choice C reason:
Referring the client to the pastoral care team could be beneficial if the client is seeking spiritual support or comfort. However, this should be based on the client's personal preferences and beliefs, and it may not be the most direct way to address the client's stated nervousness.

Choice D reason:
Engaging the client in a conversation about their feelings provides an opportunity for emotional support and can help the nurse understand the client's specific fears. This approach can lead to a more personalized care plan to alleviate anxiety.

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Correct Answer is B

Explanation

Choice A Reason:
While interviewing is a component of the nursing process, specifically during the assessment phase, describing the nursing process solely as a method for interviewing is incomplete. The nursing process encompasses much more, including diagnosis, planning, implementation, and evaluation.

Choice B Reason:
This statement accurately reflects the purpose of the nursing process. It is a systematic method used by nurses to assist clients in adapting to stressors, whether they are physical, psychological, or social. The process involves assessing the client's needs, diagnosing issues, planning and implementing interventions, and evaluating the outcomes.

Choice C Reason:
The nursing process does play a role in minimizing allegations of negligence by providing a structured approach to care, but this is not its primary purpose. The main goal is to deliver individualized and effective care to clients, not just to protect against legal issues.

Choice D Reason:
Supporting a psychiatric diagnosis is part of the nursing process, but the statement is too narrow to describe the overall purpose. The nursing process is used to plan and provide personalized care, which goes beyond just supporting a diagnosis.

A. "Don't worry. We'll take good care of your parent while you are gone." B. "You are feeling drawn in two separate directions." C. "Perhaps you could call your children to see how they are doing." D. "There's nothing you can do here. You should go home to your children."

Correct Answer is C

Explanation

Choice A reason - "Don't worry. We'll take good care of your parent while you are gone.":
This statement is meant to reassure the son that his parent will be well-cared for in his absence, which is an important concern for family members of patients. However, it does not provide any immediate comfort or solution to his dilemma of needing to be in two places at once.

Choice B reason - "You are feeling drawn in two separate directions.":
By acknowledging the son's feelings, the nurse is showing understanding and empathy. Recognizing the emotional conflict is a key step in providing emotional support, but the response stops short of offering actionable advice or comfort.

Choice C reason - "Perhaps you could call your children to see how they are doing.":
This suggestion is helpful because it gives the son a way to be involved with his children's well-being without having to leave the hospital. It's a compromise that addresses both of his concerns and can provide him with some peace of mind.

Choice D reason - "There's nothing you can do here. You should go home to your children.":
While this might be a practical suggestion, it fails to consider the son's emotional state and his need to support his hospitalized parent. It could make him feel guilty or negligent for considering leaving, even if it's to attend to his children.

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A nurse is caring for a client who is about to undergo open-heart surgery. The client states that he is very nervous about the surgery. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing instructor teaches students about the purpose of using the nursing process in the care of psychiatric clients. Which of the following statements by a student indicates that learning has occurred?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

A nurse overhears a client diagnosed with schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse should recognize the client's use of the word "flakala" as an example of which of the following alterations in speech?

A nurse on a mental health unit enters the day room and observes a client hit another client. Which of the following statements should the nurse make?

A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?

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