The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

"I am sorry to disturb you at a difficult time. This can walt until later."

“While touching the client's forearm, asks, "Would you like to talk about it?"

"This is a bad time. I can see you are upset. I can come back later."

“Gives the client a hug and says, "It is okay to cry when you are sad."

Answer and Explanation

The Correct Answer is B

A. "I am sorry to disturb you at a difficult time. This can wait until later."

This response acknowledges the client's distress but does not actively engage with the client's emotions or offer support. It also suggests postponing the assessment, which may not be necessary if the client is willing to discuss their feelings.

B. “While touching the client's forearm, asks, 'Would you like to talk about it?'"

This response demonstrates empathy and offers the client an opportunity to express their feelings if they wish to do so. By gently touching the client's forearm and asking if they would like to talk, the nurse conveys support and openness to the client's emotional needs.

C. "This is a bad time. I can see you are upset. I can come back later."

While this response acknowledges the client's emotions and offers to return later, it may not be the most helpful approach. It assumes that the client does not want to engage in conversation at that moment without giving them the opportunity to express their preferences.

D. “Gives the client a hug and says, 'It is okay to cry when you are sad.'"

While offering physical comfort like a hug can be appropriate in some situations, it's important to respect the client's personal boundaries and preferences, especially if they are in distress. Additionally, some clients may not feel comfortable with physical touch from healthcare providers. This response also assumes the client's emotions without directly addressing their needs or offering them an opportunity to express themselves verbally.

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Correct Answer is ["C","E"]

Explanation

A. Drink a mixture of warm water, whiskey, and honey at bedtime:

This suggestion is not appropriate as alcohol consumption close to bedtime can disrupt sleep patterns and exacerbate sleep problems. Additionally, alcohol can interact with medications and pose risks to health.

B. Ask the healthcare provider for a mild sedative for bedtime:

While medication may be prescribed for sleep disturbances in some cases, it should not be the first line of treatment, especially in older adults. Sedatives can have adverse effects and may lead to dependency if used long-term. Non-pharmacological interventions should be tried first.

C. Avoid drinking caffeinated beverages late in the day:

This is an appropriate suggestion. Caffeine is a stimulant that can interfere with sleep, so avoiding caffeinated beverages late in the day can help improve sleep quality.

D. Take an afternoon nap to make up for missed sleep:

While napping may be beneficial for some individuals, particularly if they are sleep deprived, it can worsen sleep difficulties in others, especially if taken late in the day. For individuals with insomnia or frequent nighttime awakenings, avoiding naps or limiting them to earlier in the day may be helpful.

E. Establish a regular time for going to bed and getting up:

This is an appropriate suggestion. Establishing a consistent sleep schedule helps regulate the body's internal clock and promotes better sleep quality. Going to bed and waking up at the same time each day, even on weekends, can help synchronize sleep-wake cycles and improve overall sleep patterns.

A. Turn the head to the right and left. B. Extend the arm at the side and rotate in circles. C. Bend the arm by flexing the ulnar to the humerus. D. Tilt the pelvis forwards and backwards.

Correct Answer is C

Explanation

A. Turn the head to the right and left:

Turning the head involves rotation of the cervical spine, which primarily consists of pivot joints rather than hinge joints. This action is more relevant to the movement of pivot joints.

B. Extend the arm at the side and rotate in circles:

Extending the arm and rotating it in circles primarily involves the movement of ball-and-socket joints, such as the shoulder joint, rather than hinge joints.

C. Bend the arm by flexing the ulna to the humerus:

This action involves bending the arm at the elbow joint by flexing the ulna (forearm bone) towards the humerus (upper arm bone). The elbow joint is a hinge joint, allowing primarily flexion and extension movements.

D. Tilt the pelvis forwards and backwards:

Tilting the pelvis forwards and backwards primarily involves the movement of ball-and-socket joints in the hip area, rather than hinge joints.

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The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","E"]

Explanation

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Correct Answer is C

Explanation

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