A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Tell me what is concerning you."

"Your husband is making really good progress."

"Did your husband say something to upset you?"

"Crying helps us let things out and we feel better."

Answer and Explanation

The Correct Answer is A

A. "Tell me what is concerning you."

This response is the most therapeutic option. It invites the spouse to share their concerns and feelings, showing empathy and active listening. It opens the door for effective communication and understanding the spouse's perspective.

B. "Your husband is making really good progress."

While this response provides information about the husband's progress, it doesn't directly address the spouse's concerns or feelings. The spouse's emotional state needs to be acknowledged and explored before discussing the husband's progress.

C. "Did your husband say something to upset you?"

This response makes an assumption that the husband said something to upset the spouse. It might come across as accusatory or dismissive of the spouse's feelings. It's important to give the spouse the opportunity to express their emotions in their own words.

D. "Crying helps us let things out and we feel better."

This response offers a general statement about crying, but it doesn't directly address the spouse's concerns or invite further conversation. While it's true that crying can be cathartic, the focus here should be on understanding the spouse's specific worries.

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Correct Answer is D

Explanation

While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.

B. Applying a cooling blanket.

While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.

C. Administering an anticonvulsant.

While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.

D. Preparing for artificial ventilation.

Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.

A. "There really isn't much you can do about that until you are discharged." B. "You should call your boss and ask if you can have your job back." C. You must feel very concerned and disappointed by that information." D. "I don't understand why your partner would upset you with news like that."

Correct Answer is C

Explanation

A. "There really isn't much you can do about that until you are discharged." - This response dismisses the client's feelings and does not offer any support.

B. "You should call your boss and ask if you can have your job back." - This response is directive and may not address the client's emotional needs.

C. "You must feel very concerned and disappointed by that information."

This response shows empathy and acknowledges the client's feelings without making judgments or offering solutions. It validates the client's emotions and opens up a supportive space for further discussion.

D. "I don't understand why your partner would upset you with news like that." - This response may be perceived as judgmental and does not show empathy or understanding.

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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

Correct Answer is D

Explanation

A nurse is caring for a client who is hospitalized and says to the nurse, "My partner called and told me my boss hired someone to take my place." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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