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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client’s reported behavior of using laxatives and inducing vomiting after eating can lead to a condition known as hypomagnesemia. Hypomagnesemia is a condition characterized by low levels of magnesium in the blood. This condition can be caused by poor intake, excessive loss, or movement of magnesium from the blood into less accessible locations. The use of laxatives can lead to excessive loss of magnesium through increased bowel movements. Similarly, self-induced vomiting can also result in a loss of magnesium. Therefore, the client’s behavior puts them at risk for developing hypomagnesemia.
Choice B rationale:
Renal failure, also known as kidney failure, occurs when the kidneys lose their ability to filter waste products from the blood. While the use of laxatives and self-induced vomiting can lead to dehydration, which can strain the kidneys, these behaviors are not directly associated with renal failure. Therefore, while it’s possible for the client to develop kidney problems, it’s less likely compared to hypomagnesemia.
Choice C rationale:
Heart failure occurs when the heart muscle doesn’t pump blood as well as it should. This condition can cause symptoms like shortness of breath, swelling, fatigue, and other symptoms. While severe electrolyte imbalances, such as those that might result from the use of laxatives and self-induced vomiting, can affect heart function, they would typically result in arrhythmias (irregular heartbeats) rather than heart failure. Therefore, it’s less likely for the client to develop heart failure based on the behaviors described.
Choice D rationale:
Hyperthyroidism is a condition where the thyroid gland produces and releases too much thyroid hormone. This condition can cause symptoms like rapid heartbeat, weight loss, and anxiety. The client’s behaviors of using laxatives and inducing vomiting after eating do not directly influence the production of thyroid hormones. Therefore, it’s less likely for the client to develop hyperthyroidism based on the behaviors described.
Correct Answer is ["1.5"]
Explanation
Step 1 is to determine the total amount of medication needed, which is 300 mg.
Step 2 is to determine the amount of medication available per tablet, which is 200 mg.
Step 3 is to calculate the number of tablets needed by dividing the total amount of medication needed by the amount available per tablet.
So, the calculation is: 300 mg ÷ 200 mg/tablet = 1.5 tablets Therefore, the nurse should administer 1.5 tablets.
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