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. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

A. "Complained about having incisional pain.” B. "Voided adequate amounts through the shift.” C. "Became short of breath when ambulating.” D. "Appeared to be sleeping while in bed.”

Correct Answer is A

Explanation

The correct answer is choice A: "Complained about having incisional pain."

Choice A rationale:

Documenting a client's complaints about pain, especially incisional pain, is crucial in an electronic health record. Pain assessment and management are essential aspects of client care, and including this information helps to track the client's pain level, the effectiveness of pain interventions, and any changes in their condition over time.

Choice B rationale:

While it's important to monitor fluid intake and output, stating that the client "Voided adequate amounts through the shift" might be relevant to the client's overall condition but lacks specific information. It doesn't address the reason for the assessment, and the focus should be on the client's immediate care needs and responses.

Choice C rationale:

Noting that the client "Became short of breath when ambulating" is significant for documenting any potential signs of respiratory distress during activity. This information provides valuable insights into the client's ability to tolerate physical exertion and might indicate a need for further assessment or interventions.

Choice D rationale:

Documenting that the client "Appeared to be sleeping while in bed" might not offer significant clinical information unless there is a specific reason for noting the client's sleep patterns. Sleep is an important aspect of recovery, but this choice lacks the context needed to make it a priority entry in the documentation.

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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 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?

Correct Answer is D

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?

Correct Answer is A

Explanation

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching?

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

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 and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

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?