A nurse is caring for a client who is visibly upset and tearful about a recent terminal diagnosis. Which of the following responses should the nurse make?

"I'm going to contact your family so they can be with you."

"I will stay with you for a while."

"I'm sorry you have to deal with this."

"When you feel better, we'll talk about your treatment options."

Answer and Explanation

The Correct Answer is B

A. "I'm going to contact your family so they can be with you.": While involving family is important, the nurse should first provide emotional support to the client. It may feel abrupt to the client if the nurse immediately redirects the focus to others without acknowledging the client's current emotional state.

B. "I will stay with you for a while.": This is correct. Offering presence and emotional support by staying with the client is an appropriate response. It shows empathy and provides the client with comfort in a time of emotional distress.

C. "I'm sorry you have to deal with this.": This is less supportive. While it acknowledges the difficulty of the situation, it could unintentionally invalidate the client’s feelings by focusing on the nurse’s perspective rather than the client's experience.

D. "When you feel better, we'll talk about your treatment options.": This is not an appropriate response. It minimizes the client’s current emotional needs and may make the client feel that their feelings are not being prioritized. The focus should be on emotional support first.

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Correct Answer is D

Explanation

A. Increased appetite: Radiation therapy, particularly to the head and neck, can cause nausea, mouth sores, and changes in taste, leading to a decrease in appetite rather than an increase.

B. Loose stools: Loose stools are not a typical side effect of external radiation for throat cancer. Radiation can affect gastrointestinal function if the abdomen or pelvis is irradiated, but it is not commonly associated with the throat area.

C. Bladder infection: Bladder infections are more likely to be associated with treatments like chemotherapy or radiation to the pelvic region, rather than radiation to the throat.

D. Loss of taste: Radiation therapy to the head and neck, including the throat, often affects the taste buds, leading to a condition called dysgeusia, or loss of taste. This is a well-known side effect of radiation in this area.

A. Turn on overhead lights briefly when checking IV lines. B. Open curtains between clients in semiprivate rooms. C. Wear shoes with rubber soles. D. Conduct change-of-shift report near the clients' rooms.

Correct Answer is C

Explanation

A. Turning on overhead lights briefly when checking IV lines is incorrect. Bright lights can disrupt sleep cycles, especially for clients who are light-sensitive or have fragmented sleep patterns. Instead, using a flashlight or bedside lamp is recommended to minimize disturbances.

B. Opening curtains between clients in semiprivate rooms is incorrect. Keeping curtains closed provides privacy and helps block light and noise, both of which can interfere with restful sleep.

C. Wearing shoes with rubber soles is correct. Rubber-soled shoes reduce noise from footsteps, minimizing disturbances in client rooms and creating a quieter environment that promotes sleep.

D. Conducting change-of-shift report near the clients' rooms is incorrect. Shift reports should be conducted away from patient areas to prevent unnecessary noise and disruption during sleep hours.

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A nurse is caring for a client who is visibly upset and tearful about a recent terminal diagnosis. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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