A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states, "I can't stand to be touched by another person." Which of the following responses should the nurse make?
"Don't worry about it. Your anxiety will lessen once the massage begins."
"Why don't you like to be touched by others?"
"I will request that the massage therapist wear gloves during your treatment."
" will tell your provider that you would like a treatment other than massage."
The Correct Answer is D
A. "Don't worry about it. Your anxiety will lessen once the massage begins."
This response dismisses the client's concerns and may not be respectful of their boundaries. It does not acknowledge the client's discomfort and does not offer a solution to address their preference.
B. "Why don't you like to be touched by others?"
While the nurse is attempting to understand the client's feelings, this question might come across as invasive or judgmental. The client may not feel comfortable discussing their reasons for not liking to be touched, and this response does not offer an immediate solution to the issue at hand.
C. "I will request that the massage therapist wear gloves during your treatment."
This response shows an attempt to accommodate the client's preference by suggesting a practical solution, such as wearing gloves to create a physical barrier. However, it's important to note that some individuals may still find this uncomfortable, and it might not be a universally effective solution for everyone.
D. "I will tell your provider that you would like a treatment other than massage."
This response acknowledges the client's discomfort and demonstrates respect for their boundaries. It indicates the nurse's intention to advocate for the client's preferences and well-being. By informing the provider about the client's aversion to touch, the nurse opens the door to exploring alternative treatment options that are more suitable for the client's comfort level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hgb 10 g/dL
Anemia (low hemoglobin levels) is a common finding in individuals with anorexia nervosa due to inadequate nutrition, leading to a decreased production of red blood cells. Hemoglobin levels below the normal range are often seen in people with severe malnutrition, such as those with anorexia nervosa.
B. Blood glucose 100 mg/dL:
A blood glucose level of 100 mg/dL is within the normal range. Anorexia nervosa typically does not cause specific changes in blood glucose levels.
C. TIBC 11 mcg/dL:
Total Iron-Binding Capacity (TIBC) is a test that measures the blood's capacity to bind to iron. The given value of 11 mcg/dL is unusually low and might not be within the typical reference range. However, the significance of this value is not clear without the specific reference range for the laboratory performing the test.
D. Potassium 3.7 mEq/L:
A potassium level of 3.7 mEq/L is within the normal range. Electrolyte imbalances, including low potassium levels (hypokalemia), can occur in individuals with anorexia nervosa due to inadequate intake and purging behaviors. While this level is within the normal range, individuals with anorexia nervosa may still exhibit electrolyte imbalances that require monitoring and management.
Correct Answer is D
Explanation
A. A client who reports that he enjoys smoking marijuana on weekends:
This situation involves an individual admitting to recreational drug use. While marijuana use might be illegal in some jurisdictions, it is generally not a reportable offense by itself unless it involves a minor. However, the nurse should educate the client about the potential risks associated with drug use.
B. A client who reports that she took $20 from the cash register where she works:
This scenario involves a confession of theft. While stealing is a legal offense, it does not fall under the category of mandatory reporting unless it involves abuse or neglect of a vulnerable population (such as elderly individuals in a care facility). The appropriate action here would be for the nurse to address the issue within the facility's protocols, but it does not require reporting to an external agency.
C. A client who reports lying to his provider about having suicidal ideation:
This situation involves dishonesty with a healthcare provider. While it is concerning behavior, it does not typically fall under the category of mandatory reporting. Instead, it highlights the importance of addressing trust issues and ensuring open communication between the client and healthcare providers.
D. A client who reports that her partner ties their child to a bed as punishment:
This scenario involves a report of child abuse. Tying a child to a bed as punishment can be considered a form of physical abuse and a violation of the child's safety and well-being. Healthcare professionals, including nurses, are mandated reporters of suspected child abuse or neglect. They are required by law to report such incidents to the appropriate child protective services agency to ensure the safety of the child involved.
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