A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." Which of the following responses should the nurse make?
"How are things going at your job?"
"Why do you think this is happening to you?"
"You must he feeling very frightened right now."
"Maybe you should think more positively."
The Correct Answer is C
A. "How are things going at your job?" This response redirects the conversation rather than addressing the client's emotional state.
B. "Why do you think this is happening to you?" This question may come across as challenging or blaming, which is not therapeutic.
C. "You must be feeling very frightened right now." This response validates the client's emotions, showing empathy and encouraging further expression of feelings.
D. "Maybe you should think more positively." This dismisses the client's distress and does not provide therapeutic support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wire cutters. This is incorrect because wire cutters are used for clients with wired jaws in case of an emergency but are not needed for chest tube management.
B. Padded clamp. This is correct because a padded clamp is necessary in case the chest tube needs to be momentarily clamped for troubleshooting air leaks or before removal.
C. Montgomery straps. This is incorrect because Montgomery straps are used to secure frequent dressing changes, such as for abdominal wounds, and are not relevant to chest tube management.
D. Tracheostomy tray. This is incorrect because a tracheostomy tray is used for clients at risk for airway obstruction, which is not a routine need following a thoracotomy with chest tube placement.
Correct Answer is A
Explanation
A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.
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