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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This response is an appropriate nursing response in this situation. It acknowledges the client's need for assistance with grocery shopping while also recognizing that shopping and personal errands are not within the nurse's job description. By suggesting to explore other resources, the nurse can help the client find alternative solutions to meet their needs. This response demonstrates a willingness to support the client and collaborate on finding appropriate assistance, while also maintaining professional boundaries and responsibilities.
A. "I won't be able to shop for you today because I have to get home to my family." This response is inappropriate because it focuses on the nurse's personal circumstances and may come across as dismissive of the client's request for help. It does not address the client's needs or offer any alternative solutions.
B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response is dismissive of the client's current situation and does not offer any practical assistance or support. It implies that the client should simply wait for their condition to improve without addressing their immediate needs.
D. "I would be happy to do whatever I can to help you." While this response may initially seem supportive, it is inappropriate because shopping and performing personal errands for the client are not within the nurse's job description. It is important for the nurse to establish professional boundaries and adhere to the responsibilities outlined in their job description.
Correct Answer is B
Explanation
By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.
Let's review the other options and explain why they are not appropriate in this situation:
A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.
C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.
D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.
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