A nurse is caring for a client who states during a counseling session, "I am sliding off a cliff." Which of the following statements should the nurse make?
"I don't think that is really what is happening to you."
"Don't worry. Everything will be okay."
"How are things going at your job?"
"You must be feeling very frightened right now."
The Correct Answer is D
A. This statement dismisses the client's feelings.
B. Offering false reassurance is not therapeutic.
C. Changing the subject does not address the client's distress.
D. This is the correct answer. Acknowledging the client's feelings is a therapeutic response that encourages further discussion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will make sure that we respect your right to refuse medications." – This response respects the client's autonomy and reassures them that their rights will be upheld.
B. "You will need to rest so that you can recover from the episode that brought you here." – This statement dismisses the client's concerns rather than addressing them.
C. "Why do you think your provider will prescribe you medications that will make you sleep?" – While open-ended questions can encourage discussion, this does not directly reassure the client about their rights.
D. "It's not your choice to be here, so you have to accept the treatment we plan for you." – This statement is inappropriate and disregards the client's legal rights.
Correct Answer is C
Explanation
A. Placing the client in Trendelenburg position is incorrect because this position does not reduce tension on the abdominal wound and may increase intra-abdominal pressure.
B. Reinserting the protruding intestinal tissue is incorrect because this can introduce infection and cause further damage.
C. This is the correct answer. The priority action is to cover the wound with a sterile, saline-moistened dressing to prevent tissue drying and reduce infection risk.
D. Monitoring vital signs is important, but the priority is to protect the exposed abdominal contents.
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