A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?
"Let's discuss some weight loss strategies that might work for you."
Have you always felt uncomfortable being overweight?"
"How long have you struggled with your weight?"
“It sounds like you're saying that you feel uncomfortable around others."
The Correct Answer is D
Rationale:
A. "Let's discuss some weight loss strategies that might work for you.": While well-intentioned, this response shifts focus prematurely to problem-solving rather than acknowledging the client's immediate emotional distress. It can come across as dismissive of the client's feelings and reinforce stigma.
B. "Have you always felt uncomfortable being overweight?": This question delves into the client's history without first validating their current emotional state. It may seem intrusive and bypasses the opportunity to provide empathy in the moment.
C. "How long have you struggled with your weight?": This response centers on the weight issue rather than addressing the client’s expressed feelings of being stared at and judged. It risks making the client feel pathologized rather than supported.
D. “It sounds like you're saying that you feel uncomfortable around others.”: This therapeutic response reflects the client's feelings, validates their emotional experience, and encourages further expression. It helps build trust and demonstrates empathy without judgment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Report the incident to the nurse manager: While reporting the error is necessary for institutional accountability and improvement, it should not take priority over assessing the client's immediate physiological response to the error.
B. Measure the client's vital signs: The nurse's first priority after a medication error is to assess the client for any adverse effects. Vital signs provide essential information about the client's condition and guide further actions to ensure safety.
C. Fill out an incident report: An incident report is a key part of documenting medication errors but is done after the client's condition has been assessed and stabilized. It is for internal use and not part of the medical record.
D. Notify the provider: The provider must be informed promptly, especially if corrective treatment is needed. However, this step comes after assessing the client's status to provide relevant clinical information during the report.
Correct Answer is D
Explanation
Rationale:
A. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is not appropriate for infants due to the risk of injury and their inability to hold the thermometer properly. It is generally reserved for children older than 4–5 years.
B. Pull the pinna of the infant's ear forward before inserting the probe: When using a tympanic thermometer for infants under 3 years, the correct method is to pull the pinna down and back, not forward, to straighten the ear canal.
C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is too invasive and risks rectal perforation. For infants, rectal insertion should be only 1.5 to 2.5 cm (0.6–1 in), with extreme caution.
D. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature is the safest and most noninvasive route for infants. Ensuring full skin contact under the center of the axilla provides the most accurate axillary reading.
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