A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?
"Have you tried leaving your house just once per day?"
"Have you thought about moving to a new neighborhood?"
"Let's discuss how you feel when you leave your house."
"Tell me why you have developed an aversion to leaving your house."
The Correct Answer is C
Choice A Reason:
"Have you tried leaving your house just once per day?" This response assumes a potential solution without fully understanding the client's feelings. It doesn't encourage open discussion or exploration of the client's anxiety.
Choice B Reason:
"Have you thought about moving to a new neighborhood?" This response jumps to a significant life change as a solution without exploring the client's current situation and emotions. It may not be a practical or necessary step.
Choice C Reason:
"Let's discuss how you feel when you leave your house." This response is an open and therapeutic approach that encourages the client to express their feelings and thoughts about the situation. It allows the nurse to gather more information and better understand the client's anxiety related to leaving the house. The other options do not facilitate open communication or exploration of the client's feelings.
Choice D Reason:
"Tell me why you have developed an aversion to leaving your house." While this response is more open-ended, it phrases the question in a somewhat confrontational manner, which might make the client defensive. The previous response ("Let's discuss how you feel when you leave your house") is gentler and inviting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Telling the client to discuss the decision with her family implies that the family should influence or make the decision for the client. The decision to continue or discontinue treatment is a personal one that the client should make based on their own values and preferences.
Choice B Reason:
Supporting the client's decision to stop the treatment is correct. When a client with end-stage kidney disease decides to stop dialysis treatment, it's essential for the nurse to respect the client's autonomy and support their decision. The client has the right to make decisions about their own healthcare, including the decision to discontinue a treatment that is no longer aligned with their goals and wishes.
Choice C Reason:
Discussing alternative treatment methods may be appropriate in some cases, but if the client has made an informed decision to stop dialysis, the focus should be on respecting and supporting that decision rather than presenting alternatives.
Choice D Reason:
Involving the facility chaplain may be beneficial if the client desires spiritual or emotional support during this difficult decision-making process, but it should be at the client's request, not imposed by the nurse.
Correct Answer is A
Explanation
a. Sounds are high-pitched.
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as in diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
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