A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

A client who plans to leave the facility against medical advice.

A client who informs the nurse that they have made their funeral arrangements.

A client who tells the nurse that the night shift nurse did not bring their medication.

A client who has just experienced the death of their child.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: A client who has just experienced the death of their child.

Choice A rationale:

Offering silence to a client who plans to leave the facility against medical advice might not be the most appropriate therapeutic communication technique. Silence in this situation could be misconstrued as ignoring the client's concerns or not addressing their reasons for wanting to leave. Active listening and open-ended questioning would likely be more effective in understanding and addressing the client's concerns.

Choice B rationale:

A client who informs the nurse that they have made their funeral arrangements is expressing thoughts and emotions that might require sensitive communication. Silence in this context could be interpreted as neglecting the client's need for support and empathy. The nurse should engage in a compassionate conversation and encourage the client to share their feelings.

Choice C rationale:

For a client who tells the nurse that the night shift nurse did not bring their medication, silence would not be the most suitable response. This situation calls for clarification and action, as the nurse needs to address the medication discrepancy promptly. Engaging in open communication and resolving the issue is essential here.

Choice D rationale:

A client who has just experienced the death of their child is likely overwhelmed with grief and intense emotions. In this scenario, using the therapeutic communication technique of silence can provide the client with a supportive space to process their feelings. Offering a moment of silence acknowledges the depth of their emotions and gives them the opportunity to express themselves when they are ready.

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Correct Answer is D

Explanation

The correct answer is choice D: "Instruct the client to tilt their head forward while eating."

Choice A rationale:

Offering the client a straw to drink liquids might not be suitable for someone with dysphagia following a stroke. Straws can sometimes contribute to aspiration risk, especially if the client has difficulty controlling their swallowing reflex. Using a straw might lead to aspiration of liquids, which can be dangerous for the client's respiratory health.

Choice B rationale:

Placing food toward the back of the client's mouth could increase the risk of choking and aspiration, especially if the client has difficulty swallowing due to dysphagia. It's important to place small bites of food at the front of the mouth and encourage slow, controlled chewing and swallowing to reduce the risk of aspiration.

Choice C rationale:

Encouraging the client to lie down and rest for 30 minutes after meals is not a recommended intervention for someone with dysphagia. This position can actually increase the risk of aspiration. The client should be in an upright position while eating and for some time after eating to allow gravity to assist in preventing aspiration.

Choice D rationale:

Instructing the client to tilt their head forward while eating helps to facilitate safer swallowing by preventing food from entering the airway. This posture helps direct the food toward the esophagus and reduces the risk of aspiration. It's an essential technique for clients with dysphagia to maintain their airway safety while eating.

A. Use warm water when bathing the client. B. Place a donut-shaped cushion in the client's chair. C. Massage reddened areas over bony prominences. D. Maintain the client in high-Fowler's position.

Correct Answer is A

Explanation

The correct answer is choice A. Use warm water when bathing the client.

Choice A rationale:

Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.

Choice B rationale:

Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.

Choice C rationale:

Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.

Choice D rationale:

Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.

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A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

Correct Answer is D

Explanation

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Correct Answer is A

Explanation

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?

A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands?

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?