A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident.

The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?

"There's nothing you can do here. You should go home to your children."

"You are feeling drawn in two separate directions."

"Perhaps you could call your children to see how they are doing."

"Don't worry.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.

Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.

Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.

Choice C rationale:

Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.

May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.

Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.

Choice D rationale:

Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.

Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.

May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.

Choice B rationale:

Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.

Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.

Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.

Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.

Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.

Choice C rationale:

Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.

A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.

Choice D rationale:

Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.

A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.

Choice B rationale:

Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.

A thorough nutritional assessment should include:

A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.

A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.

A. Phosphate level B. Capillary refill C. Sodium level D. Magnesium level E. Glucose level.

Correct Answer is ["A","B","C","D","E"]

Explanation

: The correct answer/s is Choice/s.

Choice A rationale: Phosphate level is a crucial indicator of the body’s electrolyte balance. In patients with anorexia nervosa, phosphate levels can be significantly affected due to malnutrition and the body’s metabolic response to starvation. Low phosphate levels, known as hypophosphatemia, can lead to serious complications such as muscle weakness, neurological dysfunction, and potentially life-threatening cardiac issues.

Choice B rationale: Capillary refill is a quick test performed on a patient to assess the adequacy of peripheral circulation. The time taken for color to return to an external capillary bed after pressure has been applied to cause blanching signifies the status of the patient’s peripheral blood circulation. Delayed capillary refill time may indicate shock or dehydration, which could be a concern in a patient with anorexia nervosa who may be dehydrated or malnourished.

Choice C rationale: Sodium level is another important electrolyte that needs to be monitored. Patients with anorexia nervosa can have abnormal sodium levels due to various factors such as vomiting, use of diuretics, or not consuming enough dietary sodium. Both high sodium (hypernatremia) and low sodium (hyponatremia) levels can lead to severe neurological symptoms and are considered medical emergencies.

Choice D rationale: Magnesium level is also an important consideration in patients with anorexia nervosa. Low magnesium levels, or hypomagnesemia, can occur due to inadequate dietary intake or excessive loss from the gastrointestinal tract, which can be seen in conditions like anorexia nervosa. Hypomagnesemia can lead to symptoms such as muscle cramps, seizures, and even cardiac arrhythmias.

Choice E rationale: Glucose level is a key indicator of a person’s metabolic state and energy balance. In patients with anorexia nervosa, glucose levels can be low due to inadequate food intake. Hypoglycemia, or low blood sugar, can lead to symptoms such as weakness, tremors, confusion, and in severe cases, it can be life-threatening.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat.Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

The registered nurse in the mental health unit recognizes which as being good therapeutic communication techniques? Select all that apply.

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

A mental health nurse is caring for a client who smokes and has lung cancer.The client reports, "I'm coughing because I have that cold everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms?

A nurse is reviewing the medical histories of four clients.Which of the following clients may develop extrapyramidal symptoms from medication therapy?

A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?

A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.Which of the following actions should the nurse take?

A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss.It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?