The nurse is speaking with the spouse of a client following a family discussion with the healthcare provider about the client’s terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond?
"I find it helpful to investigate the options. I will get you a pamphlet about hospice care."
"You seem overwhelmed. I’ll contact a chaplain to come and talk with you about the options."
"It’s hard to say what the best decision is, but know hospice provides wonderful care."
"These decisions are challenging. Tell me your spouse’s beliefs about end-of-life."
The Correct Answer is D
Choice A reason: Offering information is supportive, but this does not address the spouse’s emotional needs or encourage discussion about the client’s values.
Choice B reason: Calling a chaplain might be supportive later, but it avoids addressing the spouse’s statement directly and risks shifting responsibility away from the nurse.
Choice C reason: Reassurance without exploring the client’s and family’s values minimizes the spouse’s need for deeper reflection and personal decision-making.
Choice D reason: Encouraging the spouse to reflect on the client’s beliefs and values promotes autonomy and supports decision-making that honors the client’s wishes, making it the most therapeutic response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response acknowledges the client’s experience without reinforcing the hallucination. It demonstrates empathy, maintains reality orientation, and builds trust, which are crucial therapeutic approaches.
Choice B reason: Challenging hallucinations with logic is not effective and can increase client defensiveness or distress. It may also escalate paranoia rather than reduce it.
Choice C reason: Avoiding the client ignores their distress and can increase isolation. Engagement is necessary to provide reassurance and therapeutic support.
Choice D reason: Directly denying the hallucination can invalidate the client’s experience, leading to mistrust and further paranoia. A more supportive acknowledgment is preferred.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Planning alternate escape routes is a core part of safety planning, ensuring the victim can exit safely even if blocked.
Choice B reason: Having an emergency bag ready allows quick departure and reduces risk of having to return to the abuser’s home.
Choice C reason: Giving the abuser information about location compromises safety and places the victim at greater risk.
Choice D reason: Establishing a signal with trusted individuals ensures the victim can get help quickly if violence escalates.
Choice E reason: Encouraging firearm purchase is not an appropriate nursing intervention due to safety risks and escalation potential. Safer protective strategies should be emphasized.
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