A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?

"Most people are scared their first time in a health care facility."

"We can discuss what you can expect during your stay."

"You have nothing to worry about. Everything will be fine."

"Why are you feeling scared about being in this facility?

Answer and Explanation

The Correct Answer is B

"Most people are scared their first time in a health care facility":

While this statement normalizes the client's feelings by suggesting that many people feel scared initially, it might not directly address the client's specific concerns or provide the opportunity for a personalized discussion about their stay.

"We can discuss what you can expect during your stay":

This statement acknowledges the client's anxiety and opens the door for a conversation about the client's concerns. It provides an opportunity for the nurse to offer information, address specific worries, and offer support, fostering a sense of control for the client.

"You have nothing to worry about. Everything will be fine":

This statement, though well-intentioned, may come across as dismissive and overly optimistic. It might not validate the client's feelings or offer the opportunity for the client to express and discuss their concerns.

"Why are you feeling scared about being in this facility?":

While open-ended questions can help explore the client's feelings, in this context, it might be better to initially offer information and support before delving into the specific reasons for the client's anxiety. This allows the nurse to establish rapport and provide reassurance first.

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Correct Answer is B

Explanation

A. Use an 18-gauge, 1-inch needle to administer the medication.An 18-gauge needle is too large for subcutaneous heparin injections, which require a smaller, finer needle, typically 25- to 27-gauge and ⅜- to ⅝-inch in length. The smaller gauge reduces discomfort and is appropriate for subcutaneous tissue.

B. Inject 5.1 cm (2 in) away from the umbilicus.Heparin injections should be given at least 2 inches from the umbilicus to avoid areas with dense blood vessels, which decreases the risk of hematoma formation and improves medication absorption.

C. Expel air bubble before injecting medication.For prefilled heparin syringes, the small air bubble should not be expelled, as it helps ensure the full dose is administered and can reduce bruising by sealing the medication in the tissue.

D. Massage the injection site after withdrawing the needle.Massaging the site after a heparin injection is not recommended as it increases the risk of bruising and tissue irritation. Instead, gentle pressure may be applied briefly if there is bleeding at the site.

A. "You shouldn't worry about the future so you can concentrate on getting well." B. "if you work hard on your physical therapy, you won't need to worry." C. "You're concerned about what will happen when you leave the hospital?" D. "Why are you concerned even though everyone is here to help you?"

Correct Answer is C

Explanation

A. "You shouldn't worry about the future so you can concentrate on getting well.":

This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.

B. "If you work hard on your physical therapy, you won't need to worry.":

While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.

C. "You're concerned about what will happen when you leave the hospital?":

This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.

D. "Why are you concerned even though everyone is here to help you?":

This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.

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A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?

Nursing Test Bank

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