During an interaction with a client, the nurse notes the patient remains silent. What would be appropriate nurse responses for this interaction? (Select all that apply)

Sit patiently, quietly, and engaged

use open ended questions starting with Why

use open ended questions starting with Tell

Allow the client time to think a reflect

Use close ended questions to establish an increase in communication

Answer and Explanation

Correct Answer : A,C,D

A. Sit patiently, quietly, and engaged. This shows the nurse is present and supportive, allowing the client to feel comfortable and respected.
B. Use open-ended questions starting with "Why."Questions starting with "Why" can be perceived as accusatory or confrontational, potentially increasing the client's discomfort.
C. Use open-ended questions starting with "Tell." Open-ended questions encourage the client to express themselves more freely, facilitating communication.
D. Allow the client time to think and reflect. Giving the client time respects their need to process thoughts and feelings before responding.
E. Use close-ended questions to establish an increase in communication. Close-ended questions can limit responses and do not encourage the client to open up or elaborate on their feelings.

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Correct Answer is C

Explanation

A. The client will be able to lift more than 50 pounds after abdominal surgery on post-op day 1. This goal is not realistic or safe for a client post-abdominal surgery on day 1.

B. The client will be able to describe ALL the signs and symptoms of COPD. This goal is not realistic or specific enough to be measurable and achievable.

C. The client will be able to tolerate 50% of his meal at lunch. This goal is Specific, Measurable, Achievable, Relevant, and Time-bound (SMART).

D. The client states his wound is improving. This goal is not measurable or specific.

A. "The vital signs are stable" B. "The client has a history of high blood pressure" C. "The client is disoriented. Pupils are slow to respond to light." D. "The client should be seen by a neurologist."

Correct Answer is C

Explanation

A. "The vital signs are stable." This statement belongs in the Assessment (A) step, as it provides information about the client’s current clinical condition.
B. "The client has a history of high blood pressure." This statement belongs in the Background (B) step, providing relevant medical history.
C. "The client is disoriented. Pupils are slow to respond to light." The S (Situation) step involves stating the immediate problem or reason for the communication. Describing the client's disorientation and pupil response directly addresses the current issue that prompted the call.
D. "The client should be seen by a neurologist." This statement belongs in the Recommendation (R) step, suggesting the next course of action.

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During an interaction with a client, the nurse notes the patient remains silent. What would be appropriate nurse responses for this interaction? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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