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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
The correct answer/s is Choice/s.
Choice A rationale: Requesting to decrease the dose of oral glycemic medication might not be the most appropriate action for the nurse to take. The client reports overeating since they were 14 years old, which could potentially lead to obesity and related health issues such as type 2 diabetes. However, without more information about the client’s current health status and blood glucose levels, it’s not clear whether a decrease in oral glycemic medication is warranted. It’s important for healthcare providers to monitor and adjust medication dosages based on individual patient needs and responses.
Choice B rationale: Encouraging the client to eat small, frequent meals could be a beneficial strategy. Overeating can lead to weight gain and related health problems. Eating smaller meals more frequently throughout the day can help to control hunger and manage portion sizes, which could potentially help the client to reduce overeating.
Choice C rationale: Instructing the client to weigh themselves daily might not be the best approach. While it’s important for individuals to be aware of their weight as part of overall health management, daily weighing can become a source of stress and anxiety. It might be more helpful to focus on promoting healthy behaviors and coping strategies to manage overeating.
Choice D rationale: Anticipating a potassium supplement for the client might not be necessary. While potassium is an essential nutrient, there’s no indication from the information provided that the client has a potassium deficiency. Overeating does not necessarily lead to nutrient deficiencies, and supplementation should be based on individual needs and medical advice.
Choice E rationale: Teaching the client to plan meals ahead could be a very helpful strategy. Meal planning can help individuals manage portion sizes, ensure a balanced diet, and avoid impulsive eating decisions. This could potentially help the client manage their overeating.
Choice F rationale: Recommending that the client journal about their feelings could be a beneficial strategy. Emotional eating, or eating in response to feelings rather than hunger, is a common issue. Journaling can help individuals identify emotional triggers for overeating and develop healthier coping strategies.
Correct Answer is B
Explanation
Choice A rationale:
Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.
Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.
Choice C rationale:
Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.
A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.
Choice D rationale:
Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.
A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.
Choice B rationale:
Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.
A thorough nutritional assessment should include:
A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.
A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.
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