A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?
"It would be best to discuss your feelings with your provider."
"It must be very frustrating for you to be here."
"You are making progress in your treatment plan."
"You should call your partner to discuss this."
The Correct Answer is B
A. This response deflects the client's feelings and does not acknowledge the client's frustration.
B. This response acknowledges the client's feelings of frustration and validates their experience, showing empathy and understanding.
C. While it is important to encourage the client's progress, this response does not directly address the client's expressed emotions.
D. Suggesting that the client call their partner may not address the underlying feelings of frustration and may overlook the opportunity for therapeutic communication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Sedation is not typically required for PICC line insertion; local anesthesia is usually sufficient.
B: An MRI is not the standard method to verify PICC line placement; an x-ray is typically used.
C: Using gauze to secure an arm board can restrict circulation and is not recommended for securing a PICC line.
D: Measuring the arm circumference daily is important to monitor for complications such as swelling or phlebitis at the insertion site.
Correct Answer is ["B","C","E","F"]
Explanation
A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.
B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.
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