A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?
Identify other housing options and sources of transportation.
Notify the facility chaplain to request scheduling an appointment.
Confirm that everything will be all right because belongings can be replaced.
Maintain eye contact with the client and summarize the client's feelings.
The Correct Answer is D
Answer is d. Maintain eye contact with the client and summarize the client’s feelings.
a. Identify other housing options and sources of transportation: While it is essential to address practical needs such as housing and transportation for clients who have experienced a crisis like a house fire, it is not the immediate priority when the client is in acute emotional distress. In this scenario, the client is expressing emotional distress and may not be ready to focus on practical solutions. Therefore, addressing the client's emotional needs should take precedence over addressing practical concerns.
b. Notify the facility chaplain to request scheduling an appointment: While spiritual support can be beneficial for individuals coping with trauma or loss, it should not be the immediate response when a client is in acute emotional distress. While the chaplain's support may be sought later as part of the client's holistic care, it should not precede addressing the client's immediate emotional needs.
c. Confirm that everything will be all right because belongings can be replaced: This option is incorrect because it offers false reassurance and dismisses the client's feelings about their loss. While it is true that belongings can be replaced, the emotional impact of losing possessions, especially in a traumatic event like a house fire, should not be trivialized. The client's feelings of distress and uncertainty are valid and should be acknowledged and addressed by the nurse.
d. Maintain eye contact with the client and summarize the client’s feelings: Correct. This action demonstrates therapeutic communication, which is crucial in providing an atmosphere of support and safety for the client. Maintaining eye contact shows empathy, support, and advocacy, indicating to the client that their feelings are being heard and validated. Summarizing the client's feelings allows the nurse to demonstrate active listening and understanding, fostering trust and rapport between the nurse and client. By prioritizing the client's emotional needs, the nurse can help the client begin to process their feelings and move towards coping and problem-solving.
In summary, the correct answer is d because maintaining eye contact with the client and summarizing their feelings demonstrates therapeutic communication, which is essential in providing support and validation for the client's emotional distress. This approach allows the nurse to establish rapport and trust with the client, facilitating further therapeutic interventions and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. A room containing personal belongings.
Choice A rationale:
Similar to the rationale provided for , a room without a window would not provide the necessary sensory input and connection to the outside world. Natural light and visual stimuli are important for maintaining a sense of time and orientation.
Choice B rationale:
A room containing personal belongings is the correct answer for the same reasons as mentioned in the previous question. Familiar items can provide comfort and reduce feelings of agitation in cognitively impaired individuals.
Choice C rationale:
Once again, a room adjacent to the nursing station could expose the client to unnecessary noise and activity, potentially causing distress and hindering the therapeutic environment required for cognitively impaired individuals.
Choice D rationale:
Dim lighting can contribute to disorientation and confusion. Adequate lighting helps individuals perceive their surroundings and reduces the risk of accidents.
Correct Answer is D
Explanation
Choice A rationale:
The client taking an overdose of the medication is unlikely to be the cause of the symptoms. Disulfiram (Antabuse) is a medication used to treat alcohol dependence by causing adverse effects when alcohol is consumed. However, an overdose would not result in severe nausea and vomiting as described.
Choice B rationale:
Experiencing common side effects of the medication is a possibility, but severe nausea and vomiting are not typical side effects of disulfiram. The medication's primary purpose is to induce unpleasant effects when alcohol is consumed, not to cause severe gastrointestinal symptoms.
Choice C rationale:
Demonstrating an allergic response to the medication could potentially cause various symptoms, but severe nausea and vomiting are not commonly associated with allergies to disulfiram. Allergic reactions often manifest as skin rashes, itching, and respiratory symptoms, which are not described in this scenario.
Choice D rationale:
The correct choice. Disulfiram works by inhibiting alcohol metabolism, leading to the accumulation of acetaldehyde, a toxic substance, when alcohol is consumed. This buildup of acetaldehyde results in unpleasant symptoms like severe nausea, vomiting, headache, and flushing. Since the client has recently started taking disulfiram and reports experiencing severe nausea and vomiting after discontinuing the medication, it is most likely that the client consumed alcohol while taking the medication, triggering the adverse reaction.
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