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 C

Explanation

A. "A nurse discusses a client's postoperative complications during shift report.": This is not a breach of confidentiality if the information is shared within the context of a healthcare team for the purpose of providing care. Confidentiality is maintained as long as the information is shared appropriately.

B. "A facility risk manager includes information from a client's medical record in a when report.": This is also not necessarily a breach of confidentiality if the report is used for quality improvement, risk management, or other institutional purposes where confidentiality protocols are followed.

C. "A nurse tells the chaplain that a client has a new diagnosis of cancer.": This is a breach of confidentiality. Information should only be shared with others involved in the patient's care or if the patient has given explicit consent. Discussing a client's diagnosis with a chaplain or anyone not directly involved in the care plan is an unauthorized disclosure.

D. "A social worker reads a client's chart as a follow-up to a requested consultation.": This is not a breach of confidentiality if the social worker is following established protocols for patient care and is authorized to access the client's medical records for consultation purposes.

A. Apply an ice pack to the affected extremity for 20 min every 2 hr. B. Massage the affected extremity every 4 hr. C. Administer aspirin for pain. D. Initiate bed rest.

Correct Answer is A

Explanation

A. Apply an ice pack to the affected extremity for 20 min every 2 hr.: Applying ice to the affected extremity can help reduce inflammation and discomfort associated with deep-vein thrombosis (DVT). This method is often recommended to decrease swelling and prevent further complications.

B. Massage the affected extremity every 4 hr.: Massage should be avoided in cases of DVT as it can dislodge the thrombus, leading to a pulmonary embolism or other life-threatening complications.

C. Administer aspirin for pain.: Aspirin is not recommended for clients on anticoagulant therapy, as it can increase the risk of bleeding. Other pain relief options should be considered that do not interact with anticoagulants.

D. Initiate bed rest.: While limited activity is necessary to prevent the risk of embolism, complete bed rest is not typically recommended. Early ambulation (when safe. is often encouraged to prevent complications like venous stasis.

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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

A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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