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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Hearing difficulties can be a challenge but do not necessarily indicate social isolation unless they lead to withdrawal from activities.
B. Babysitting twice a month still allows for social interaction and does not suggest isolation.
C. Not attending church due to a lost hearing aid suggests withdrawal from social activities, which increases the risk of social isolation.
D. Having a family member assist with grocery shopping indicates some level of social interaction and support, reducing the risk of isolation.

A. A client who has heart failure and received furosemide IV 8 hr ago B. A client who was admitted 24 hr ago with chest pain C. A client who had a seizure 48 hr ago and is on seizure precautions D. A client who is scheduled to have a colonoscopy in 12 hr

Correct Answer is D

Explanation

A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.

B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.

C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.

D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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