A nurse is collecting data from a client who is admitted to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

"It's okay to feel afraid. Let's talk about what you are afraid of."

"Your doctor is a great surgeon. You will be fine."

"Don't worry. The important thing is you have now quit smoking."

"I understand your fears. I was a smoker also."

Answer and Explanation

The Correct Answer is A

The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.

Choice B, "Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.

Choice C, "Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.

Choice D, "I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.

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Correct Answer is B

Explanation

When a patient with heart failure begins treatment with an ACE inhibitor, the nurse should prioritize monitoring the patient's blood pressure because ACE inhibitors can cause hypotension. Oxygen saturation, choice A, may be important to monitor in some cases, but it is not the priority in this situation. Level of consciousness, choice C, and assessment for nausea, choice D, may also be important but are not the priority assessments in this situation.

A. "You are probably right. Soiling the bed is a way of getting attention from the nursing staff." B. "Tell me what makes you feel the client is doing this on purpose?" C. "Why don't you spend more time with the client if you think that she is trying to get attention?" D. "Next time this happens, tell me and I'll talk to the client about his behavior."

Correct Answer is B

Explanation

When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.

Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.

Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.

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A nurse is collecting data from a client who is admitted to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with heart failure has met with their primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, which assessment should the nurse prioritize?

Correct Answer is B

Explanation

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

Correct Answer is B

Explanation

A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?

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A nurse is collecting data on an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following manifestations should the nurse expect to find?

A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?