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 ["C","D","E"]
Explanation
When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹.
The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹.
Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.
Correct Answer is A
Explanation
Choice A Reason:
Changing a central venous catheter dressing for a client who is receiving IV therapy is correct. Sterile gloves should be used when performing procedures that involve the manipulation of sterile or aseptic areas, such as changing the dressing on a central venous catheter. Maintaining the sterility of the catheter site is crucial to prevent infections in clients receiving IV therapy through central lines.
Choice B Reason:
Instilling an ophthalmic ointment for a client with a corneal abrasion involves applying a medication to the eye is incorrect. While it's important to use clean technique and maintain good hand hygiene, it does not require sterile gloves.
Choice C Reason:
Inserting an NG (nasogastric) tube for enteral feedings is a clean procedure, not a sterile one. Clean gloves are typically used to maintain cleanliness and reduce the risk of infection, but full sterile technique is not necessary.
Choice D Reason:
Administering an IM (intramuscular) injection also does not require sterile gloves. Clean gloves should be used to maintain infection control, but full sterile technique is not needed for routine IM injections.
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