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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
Correct Answer is A
Explanation
The correct answer is choice A. Perform a bladder scan.
Choice A rationale:
Performing a bladder scan is the first action the nurse should take before proceeding with intermittent urinary catheterization. A bladder scan assesses the bladder's volume and determines if catheterization is necessary. It helps avoid unnecessary catheterizations, reduces the risk of infection, and promotes patient comfort.
Choice B rationale:
While cleansing the meatus and providing perineal care are important steps in preparing for urinary catheterization, they come after assessing the need for catheterization. Without knowing the bladder volume, these actions could be premature.
Choice C rationale:
Providing perineal care is important for maintaining hygiene and preventing infection, but it should be done after the decision for catheterization has been made based on the bladder scan results.
Choice D rationale:
Lubricating the catheter is a step that should be taken after the decision for catheterization is made and the need for catheterization is confirmed. It helps ease the insertion process and reduce discomfort for the patient.
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