A nurse is assessing a client who is about to undergo a left lobectomy to treat lung cancer. The client expresses fear and regret about her past smoking habit.
How should the nurse respond?
"It's okay to feel scared. Let's talk about what you are afraid of."
"Don't worry. The important thing is you have now quit smoking."
"Your doctor is a great surgeon. You will be fine."
"I understand your fears. I was a smoker also."
The Correct Answer is A
Choice A rationale:
It's okay to feel scared. Let's talk about what you are afraid of.
Acknowledges the client's feelings: This response directly acknowledges the client's fear and regret, which is a crucial first step in providing emotional support. It validates the client's experience and creates a safe space for open communication.
Invites the client to share: By inviting the client to talk about their fears, the nurse encourages open expression of emotions. This can help the client to process their feelings and gain a sense of control over their situation.
Promotes understanding: By actively listening to the client's concerns, the nurse can gain a better understanding of their individual needs and fears. This understanding can then guide the nurse in providing tailored support and interventions.
Facilitates coping: Talking about fears can help the client to identify and explore coping strategies. The nurse can assist in this process by offering suggestions, providing resources, and teaching relaxation techniques.
Strengthens the nurse-client relationship: By demonstrating empathy, active listening, and support, the nurse can foster a trusting relationship with the client. This relationship can provide a source of comfort and reassurance during a challenging time.
Choice B rationale:
Don't worry. The important thing is you have now quit smoking.
Dismisses the client's feelings: This response minimizes the client's fear and regret, which can be invalidating and hinder emotional expression.
Focuses on the past: While it's important to acknowledge the positive step of quitting smoking, this response shifts the focus away from the client's current emotional state and concerns about the upcoming surgery.
Offers false reassurance: Telling the client not to worry can be unrealistic and unhelpful, as it doesn't address the underlying fears.
Choice C rationale:
Your doctor is a great surgeon. You will be fine.
Provides premature reassurance: While it's appropriate to express confidence in the medical team, this response may not fully address the client's emotional needs. It can also inadvertently downplay the seriousness of the surgery and potential risks.
Shifts focus away from the client: This response focuses on the surgeon's skills rather than the client's feelings and concerns.
Choice D rationale:
I understand your fears. I was a smoker also.
May be perceived as self-focused: While sharing a personal experience can sometimes build rapport, it's important to ensure the focus remains on the client's needs and experiences. This response could inadvertently shift the attention to the nurse's own story.
Does not directly address the client's fears: While expressing understanding can be helpful, it's important to follow up with s and encouragement to explore the client's specific concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer/s is C
Choice A rationale: Hyperkalemia, or high potassium levels in the blood, is not typically associated with anorexia nervosa. In fact, individuals with anorexia nervosa are more likely to experience hypokalemia, or low potassium levels, due to inadequate dietary intake and excessive loss of potassium through vomiting or use of diuretics1.
Choice B rationale: Metrorrhagia, or irregular menstrual bleeding between periods, can occur in females with anorexia nervosa due to hormonal imbalances caused by extreme weight loss and malnutrition. However, amenorrhea, or the absence of menstruation, is more commonly observed1.
Choice C rationale: Lanugo, which is fine, soft hair that grows on the face and body, is a common finding in individuals with anorexia nervosa. It is the body’s response to severe weight loss and starvation as an attempt to provide insulation and maintain body temperature1.
Choice D rationale: Tachycardia, or a rapid heart rate, is not typically associated with anorexia nervosa. Instead, individuals with anorexia nervosa often experience bradycardia, or a slower than normal heart rate, as the body’s response to starvation1.
Correct Answer is ["A","B","C","D","E"]
Explanation
: The correct answer/s is Choice/s.
Choice A rationale: Phosphate level is a crucial indicator of the body’s electrolyte balance. In patients with anorexia nervosa, phosphate levels can be significantly affected due to malnutrition and the body’s metabolic response to starvation. Low phosphate levels, known as hypophosphatemia, can lead to serious complications such as muscle weakness, neurological dysfunction, and potentially life-threatening cardiac issues.
Choice B rationale: Capillary refill is a quick test performed on a patient to assess the adequacy of peripheral circulation. The time taken for color to return to an external capillary bed after pressure has been applied to cause blanching signifies the status of the patient’s peripheral blood circulation. Delayed capillary refill time may indicate shock or dehydration, which could be a concern in a patient with anorexia nervosa who may be dehydrated or malnourished.
Choice C rationale: Sodium level is another important electrolyte that needs to be monitored. Patients with anorexia nervosa can have abnormal sodium levels due to various factors such as vomiting, use of diuretics, or not consuming enough dietary sodium. Both high sodium (hypernatremia) and low sodium (hyponatremia) levels can lead to severe neurological symptoms and are considered medical emergencies.
Choice D rationale: Magnesium level is also an important consideration in patients with anorexia nervosa. Low magnesium levels, or hypomagnesemia, can occur due to inadequate dietary intake or excessive loss from the gastrointestinal tract, which can be seen in conditions like anorexia nervosa. Hypomagnesemia can lead to symptoms such as muscle cramps, seizures, and even cardiac arrhythmias.
Choice E rationale: Glucose level is a key indicator of a person’s metabolic state and energy balance. In patients with anorexia nervosa, glucose levels can be low due to inadequate food intake. Hypoglycemia, or low blood sugar, can lead to symptoms such as weakness, tremors, confusion, and in severe cases, it can be life-threatening.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.