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?
"How long have you struggled with your weight?"
"Let's discuss some weight loss strategies that might work for you."
"It sounds like you're saying that you feel uncomfortable around others."
"Have you always felt uncomfortable being overweight?"
The Correct Answer is C
A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Miosis : Pinpoint pupils are a hallmark of opioid overdose due to stimulation of the parasympathetic nervous system. This finding helps distinguish opioid toxicity from other types of substance use, which often cause pupil dilation instead.
Respiratory depression : Opioids depress the medullary respiratory centers in the brainstem, leading to slowed breathing. A respiratory rate of 10/min is significantly reduced and signals impaired ventilation, making it a critical diagnostic clue.
Opioid overdose: The clinical signs—needle marks, sedation, pinpoint pupils, bradypnea, and a positive response to naloxone—all strongly point to an opioid overdose. A similar prior episode adds to the likelihood of chronic opioid misuse.
Alcohol intoxication: While alcohol can depress the central nervous system, it does not typically cause miosis or respond to naloxone. Also, the pattern of rapid reversal with naloxone suggests opioid involvement rather than alcohol alone.
Benzodiazepine overdose: Though it shares features like sedation and respiratory depression with opioid overdose, benzodiazepine toxicity does not cause miosis, and naloxone has limited or no effectiveness as a reversal agent.
Cocaine intoxication : Typically causes stimulant effects including mydriasis (dilated pupils), increased heart rate, hypertension, and agitation. These are not consistent with the symptoms in this case, which reflect CNS depression.
Correct Answer is B
Explanation
A. A client who has a fracture and is in balance suspension traction. This client is non-ambulatory and difficult to move quickly, so should not be evacuated first unless they are in immediate danger. They would require additional assistance and equipment to move safely.
B. A client who is ambulatory and receiving oxygen. This client is able to walk independently and can evacuate with minimal assistance, even while on oxygen. Evacuating ambulatory clients first helps clear the area quickly and frees up staff to assist less mobile clients.
C. A client who uses a wheelchair and is confused. While this client needs help due to confusion and mobility limitations, they are not the priority for first evacuation unless in immediate danger. They require more time and assistance.
D. A client who is bedridden and wears a hearing aid. This client is non-ambulatory and may have communication challenges, which makes evacuation more complex. They would be evacuated after ambulatory clients for safety and efficiency.
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