The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer
"Alcoholism is a disease that affects the whole family.”
"You sound frustrated in dealing with your wife’s drinking problem.”
"I think you are a good person to stay here with your wife.”
“Have you discussed this subject at the support group meetings?”
The Correct Answer is B
Choice A reason: "Alcoholism is a disease that affects the whole family.” is not the best response to the client’s husband. This response shows generalization, which is a communication technique that involves using statements that apply to most people in similar situations. It also shows lecturing, which is a communication barrier that involves giving unsolicited advice or information to the other person. It may make the client’s husband feel stereotyped, judged, or patronized, and may discourage further communication. Therefore, this choice is incorrect.
Choice B reason: "You sound frustrated in dealing with your wife’s drinking problem.” is the best response to the client’s husband. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s husband’s emotions, and invites him to express his concerns or fears. Therefore, this choice is correct.
Choice C reason: "I think you are a good person to stay here with your wife.” is not the best response to the client’s husband. This response shows praise, which is a communication technique that involves giving positive feedback or recognition to the other person. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It may make the client’s husband feel uncomfortable, embarrassed, or pressured, and may not address his underlying feelings or needs. Therefore, this choice is incorrect.
Choice D reason: “Have you discussed this subject at the support group meetings?” is not the best response to the client’s husband. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows probing, which is a communication barrier that involves asking too many or inappropriate questions to the other person. It may make the client’s husband feel defensive, invaded, or resentful, and may violate his privacy or confidentiality. Therefore, this choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.
Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.
Choice C reason: Signs of fluid overload are objective data that indicate excess fluid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,
kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of fluid overload, but signs of fluid deficit or heat stroke. Therefore, this choice is incorrect.
Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: The nursing assistant is speaking in a normal tone is an action that the PN should not intervene in during communication with the client who is hearing impaired. Speaking in a normal tone can help the client to hear the natural variations and inflections of the voice, and to avoid distortion or confusion. Speaking in a high-pitched or
low-pitched tone can make the voice harder to hear or understand, especially if the client has a hearing loss in a specific frequency range. Therefore, this choice is correct.
Choice B reason: The nursing assistant is facing the client while speaking is an action that the PN should not intervene in during communication with the client who is hearing impaired. Facing the client while speaking can help the client to see the facial expressions and lip movements of the speaker, and to enhance visual cues and feedback. Facing away from the client while speaking can make the voice muffled or unclear, and can interfere with eye contact or rapport. Therefore, this choice is correct.
Choice C reason: The nursing assistant is speaking directly into the impaired ear is an action that the PN should intervene in during communication with the client who is hearing impaired. Speaking directly into the impaired ear can create an uncomfortable or unnatural position for the client and the speaker, and interfere with eye contact or facial expressions. Speaking directly into the impaired ear can also create a loud or distorted sound that may be unpleasant or painful for the client. Speaking face-to-face, and slightly toward the unaffected ear, can improve communication with a client who is hearing impaired. Therefore, this choice is incorrect.
Choice D reason: The nursing assistant is speaking clearly to the client is an action that the PN should not intervene in during communication with the client who is hearing impaired. Speaking clearly to the client can help the client to hear and understand the words and sentences of the speaker, and to avoid miscommunication or misunderstanding. Speaking unclearly to the client can make the voice garbled or incomprehensible, and can cause frustration or confusion. Therefore, this choice is correct.
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