A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the "E” in the NURSE mnemonic?
" It sounds like you are exhausted."
"Tell me more about how you are feeling"
"You have so much to deal with. How can I be of help to you?"
"It is impressive how you have managed to deal with the situation"
The Correct Answer is A
A. "It sounds like you are exhausted."
This response demonstrates empathy and acknowledges the client's emotional state. The "E" in the NURSE mnemonic stands for "empathize," which involves recognizing and validating the client's feelings. By acknowledging that the client may be exhausted, the nurse shows understanding and empathy towards the client's experience of feeling overwhelmed.
B. "Tell me more about how you are feeling."
This response demonstrates active listening and encourages the client to express their emotions further. While important for therapeutic communication, it does not specifically address the client's feeling of being overwhelmed as directly as option A.
C. "You have so much to deal with. How can I be of help to you?"
This response demonstrates support and willingness to assist the client but does not directly address the client's reported feeling of being overwhelmed.
D. "It is impressive how you have managed to deal with the situation."
This response offers praise but does not directly address the client's reported feeling of being overwhelmed. It may also inadvertently minimize the client's feelings by focusing on their ability to cope rather than acknowledging their current emotional state.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.
B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.
C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.
D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.
Correct Answer is C
Explanation
A. You should advance your weak leg forward to the cane, then move your strong leg:
Advancing the weak leg first and then the strong leg is not the proper technique for using a cane. The correct method is to hold the cane on the stronger side and move the cane and the weaker leg forward together, followed by the stronger leg.
B. You should advance the cane 12 to 14 inches before taking a step:
Advancing the cane 12 to 14 inches is too far. The cane should be advanced approximately 6 to 10 inches to maintain balance and support.
C. The cane’s height should be the same as the distance from the floor to the crest of your hip bone:
The correct height for a cane is when the handle is at the level of the wrist when the user is standing with the arm hanging naturally at their side. This typically corresponds to the distance from the floor to the greater trochanter (hip bone). This ensures the cane provides the right amount of support and reduces the risk of strain or imbalance.
D. You should hold the cane in your weak hand when ambulating:
The cane should be held in the stronger hand, not the weak hand. This allows the cane to provide support to the weaker side of the body and helps to balance the weight distribution more effectively.
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