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 D

Explanation

A. How many popsicles are available.

This information might be helpful for logistical purposes or to assess how much the child has consumed, but it's not directly relevant to ensuring the appropriateness of the popsicles for a clear liquid diet.

B. If the popsicles are completely frozen.

While it's important that popsicles are properly frozen to avoid potential choking hazards, this does not address whether the popsicles meet the dietary requirement of clear liquids.

C. The color and flavor of gelatin used.

While this might be of interest, the key concern is whether the popsicles contain any non-clear components like fruit or pulp.

D. Whether they contain pulp or fruit.

For a child who needs clear liquids, it is important to ensure that the popsicles do not contain any solids like fruit or pulp. Clear liquids are meant to be easily digestible and not irritate the stomach further. Popsicles with pulp or fruit can be too heavy and might not be appropriate in this situation.

A. Provide a back rub at bedtime. B. Leave the door to the client's room open slightly. C. Apply wrist restraints to prevent wandering. D. Administer a PRN sedative prescription.

Correct Answer is A

Explanation

A. Provide a back rub at bedtime:

This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.

B. Leave the door to the client's room open slightly:

Leaving the door open may not prevent wandering and could potentially lead to safety issues.

C. Apply wrist restraints to prevent wandering:

Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.

D. Administer a PRN sedative prescription:

Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

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