A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
"Aren't you interested in learning how to perform this test?"
"Let's talk about what forethinking."
"I'll discuss this with your partner instead."
"Is this something you think you can do?"
The Correct Answer is B
Choice A Reason:
"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.
Choice B Reason:
"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.
Choice C Reason:
"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.
Choice D Reason:
"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.
Choice B Reason:
Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.
Choice C Reason:
Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.
Choice D Reason:
Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.
Correct Answer is B
Explanation
Choice A Reason:
"I'm sure it's nothing serious and their appetite will return soon." Is incorrect. This response dismisses the concern without addressing the underlying issue. It might overlook potential reasons for the lack of appetite and could lead to neglecting a serious problem.
Given the concern about the client not eating, the most appropriate response for the nurse to make would be:
Choice B Reason:
"Tell me more about what happens at mealtime." Is correct. This response encourages the child to share specific details about the mealtime routine, any challenges, or reasons behind the lack of eating. It allows the nurse to gather more information, identify potential issues, and offer appropriate guidance or interventions. Understanding the context surrounding the eating habits can help determine the best approach to address the situation effectively.
Choice C Reason:
"Why do you think they're not eating?" is incorrect. While it encourages discussion, this response puts the responsibility on the child to provide explanations that they might not fully understand or be equipped to articulate. It's essential for the nurse to gather information but in a more supportive and guiding manner.
Choice D Reason:
"They may need a feeding tube." Is incorrect. Jumping to a conclusion about a feeding tube without gathering more information or exploring other possibilities could alarm the child unnecessarily. This response could also create unnecessary worry for the child and the family without assessing the situation comprehensively.
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