A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make?

"You are in really good shape for your age."

"This is just a minor setback. You will be back on your feel in no time."

"The doctors are going to take good care of you. There is nothing to worry about."

“You feel as though your life is ending?"

Answer and Explanation

The Correct Answer is D

This response reflects the therapeutic communication technique of reflection and validation. By acknowledging the client's feelings and reflecting on them back, the nurse shows empathy and encourages further discussion. It allows the client to express their emotions and concerns, fostering a trusting and supportive relationship between the nurse and the client.

incorrect:

A. "You are in really good shape for your age." This response dismisses the client's expressed feelings of despair and does not address the underlying emotions. It fails to acknowledge the client's emotional state and may minimize their concerns.

B. "This is just a minor setback. You will be back on your feet in no time." While the intention may be to provide reassurance, this response invalidates the client's feelings of hopelessness and disregards the significance of their emotional experience. It does not address the client's statement of feeling that their time is up.

C. "The doctors are going to take good care of you. There is nothing to worry about." This response focuses solely on the medical aspect of care and may disregard the client's emotional and existential concerns. It fails to acknowledge the client's expressed feelings of their time being up and does not encourage further exploration of their emotions.

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Correct Answer is D

Explanation

The appropriate response by the nurse in this situation is to set clear boundaries and remove themselves from the situation. By stating, "I'm going to leave now and I'll return in one hour to spend time with you then," the nurse establishes that the inappropriate behavior is not acceptable and that they will return later to continue providing care within professional boundaries.

A- "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior" is not an appropriate response. Ignoring the behavior can potentially enable or encourage further inappropriate advances, and it does not address the issue directly.

B- "I'm curious as to why you are behaving this way. Can you please explain it to me?" places the responsibility on the client to explain their behavior, which is not appropriate or necessary in this situation. It may also encourage further discussion of the inappropriate behavior.

C- "I'm very flattered, but I am married and cannot engage in this behavior" personalizes the situation and may give the wrong impression that the nurse's marital status is the reason for rejecting the advances. It is important to maintain professional boundaries and not involve personal factors in the response.

A. "I will assist you in getting out of bed and getting dressed." B. "You can remain in bed until you feel well enough to join the milieu." C. "The unit rules state that clients may not remain in bed." D. "If you don't participate in your care, you will not get better."

Correct Answer is A

Explanation

The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.

The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.

The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.

The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.

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A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who begins to make sexual advances towards him. Which of the following is an appropriate statement by the nurse?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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