A nurse is caring for a client who is angry and states, "The doctor gave me the wrong information. I was lied to!" Which of the following responses by the nurse is appropriate?

"Your doctor has an excellent reputation for being honest with clients."

"Why do you think the doctor is lying?"

"You feel as if the doctor hasn't been honest with you?"

"I am certain the doctor would not lie to you."

Answer and Explanation

The Correct Answer is C

Choice A Reason:
"Your doctor has an excellent reputation for being honest with clients." This response is incorrect. While intending to provide reassurance, this statement may come across as dismissive of the client's feelings and might not address their immediate concern.

Choice B Reason:
"Why do you think the doctor is lying?" This response is incorrect. This response might come off as confrontational or defensive. It could potentially escalate the client's emotions and not effectively address their feelings of being misled.

Choice C Reason:
"You feel as if the doctor hasn't been honest with you?" This response acknowledges the client's emotions and concerns without making assumptions about the doctor's actions. It demonstrates empathy and allows the client to express their feelings and concerns further.

Choice D Reason:
"I am certain the doctor would not lie to you." This response might be perceived as dismissive or invalidating of the client's feelings and beliefs, as it asserts the nurse's certainty without fully understanding the client's perspective.

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Correct Answer is B

Explanation

Choice A Reason:

"I'll listen to my favorite music to take my mind off the pain." This statement refers to distraction techniques, like listening to music, which can help manage pain but isn't specifically guided imagery.

Choice B Reason:

"I'll think about my grandfather's farm to reduce pain." This statement indicates an understanding of this technique. Guided imagery involves creating a detailed mental image or scenario that promotes relaxation and diminishes pain perception. In this case, the client visualizing a familiar, pleasant place like their grandfather's farm can be an effective form of guided imagery to alleviate pain by diverting attention and inducing relaxation.

Choice C Reason:

"I'll use focused breathing to control my pain." This statement does not indicate an understanding of this technique.

Focused breathing, while beneficial for relaxation and pain management, is a different technique from guided imagery.

Choice D Reason:

"I'll learn to notice the sensation of muscle tension." This statement refers to progressive muscle relaxation, a technique involving systematically tensing and relaxing muscle groups, which isn't guided imagery.

A. Check a client's peripheral IV site for redness or swelling. B. Measure the intake and output of a client who has received furosemide. C. Reinforce teaching with a client about crutch-gait walking. D. Assess the pain level of a client who has received acetaminophen.

Correct Answer is B

Explanation

A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.

B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.

C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.

D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.

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A nurse is caring for a client who is angry and states, "The doctor gave me the wrong information. I was lied to!" Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

Correct Answer is B

Explanation

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is B

Explanation

A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

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A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

A nurse is caring for a client who fell while walking to the bathroom. Which of the following actions should the nurse take when completing the incident report?

A nurse is collecting data from a client who is receiving IV fluid replacement to treat diarrhea but now has oliguria. Laboratory results include a potassium level of 5.6 mEq/L. The nurse should report which of the following findings to the provider immediately?

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