An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?
"You are probably right. Soiling the bed is a way of getting attention from the nursing staff."
"Tell me what makes you feel the client is doing this on purpose?"
"Why don't you spend more time with the client if you think that she is trying to get attention?"
"Next time this happens, tell me and I'll talk to the client about his behavior."
The Correct Answer is B
When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.
Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.
Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
"The client reports his heart is beating out of his chest." as this symptom is consistent with anxiety and the client's prescription is for PRN anxiety. Alprazolam is a medication used to treat anxiety disorders and symptoms of anxiety.
Choice A, "The client pretends to be a government agent," is not a symptom that would be treated with alprazolam.
Choice B, "The client reports seeing bugs crawling on the walls," may indicate the presence of a hallucination or other mental health symptom, but is not related to anxiety and is not an appropriate indication for alprazolam.
Choice C, "The client describes an increase in pain after receiving meperidine," indicates a potential adverse drug effect and is not related to anxiety or an indication for alprazolam.
Correct Answer is D
Explanation
When collecting data from a female client who has anorexia nervosa, the nurse should expect a finding of low bone density.
Anorexia nervosa is an eating disorder characterized by self-starvation, distorted body image, and a fear of gaining weight. Clients with anorexia nervosa are at risk for severe malnutrition, which can lead to a variety of complications, including bone loss and osteoporosis.
Options A, B, and C are incorrect findings in a client with anorexia nervosa. Decreased cholesterol levels may be an indication of malnutrition. Heavy monthly periods, or menstrual irregularities, may occur in clients with anorexia nervosa because of the hormonal changes that can result from severe weight loss. Elevated serum potassium levels are not a common finding in a client with anorexia nervosa.
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