A patient who is experiencing moderate anxiety says, "l feel undone." An appropriate response for the registered nurse who needs clarification would be:
Select one:
I’m not sure I understand. Please give me an example...
"Can you explain me everything again?"
"Why do you feel like that? What would you like me to do to help you?"
You must get your feelings under control before we can continue."
The Correct Answer is A
This response is appropriate because it seeks clarification and more information to help the nurse better understand the patient's statement. By asking for an example, the nurse can gain a better understanding of the patient's experience and identify appropriate interventions to help the patient manage their anxiety.
Option b is not an appropriate response as it does not seek clarification and instead asks the patient to repeat themselves.
Option c is partially appropriate but could be improved by asking more specific questions to help the patient articulate their feelings and needs.
Option d is not an appropriate response as it dismisses the patient's feelings and may cause the patient to feel unsupported and isolated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Denial is a defense mechanism where an individual refuses to accept or acknowledge the existence of a problem or a reality that causes anxiety or distress. In this scenario, the client is denying that their coughing is related to their lung cancer, and instead attributing it to a common cold that everyone is getting. This denial may be a way for the client to avoid facing the reality of their illness and the potential consequences of smoking.
Option b, reaction formation, is a defense mechanism where an individual expresses feelings or behaviors that are the opposite of their true feelings to reduce anxiety.
Option c, sublimation, is a defense mechanism where an individual channels their unacceptable impulses into more acceptable or socially appropriate behaviors.
Option d, suppression, is a defense mechanism where an individual consciously pushes down or avoids their thoughts or feelings. None of these defense mechanisms are being exhibited in the scenario described.

Correct Answer is C
Explanation
During the termination phase of the nurse-client relationship, the nurse should focus on making appropriate referrals to ensure that the client continues to receive the care and support they need after the relationship with the nurse has ended.
Option a. Developing realistic solutions is an important task during the working phase of the nurse-client relationship, when the nurse and client work together to identify and implement solutions to the client’s problems.
Option b. Building rapport and trust is an important task during the orientation phase of the nurse-client relationship, when the nurse and client get to know each other and establish a therapeutic relationship.
Option d. Identifying expected outcomes is an important task during the planning phase of the nursing process, when the nurse and client work together to set goals and develop a plan of care.
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