Which of the following actions should the nurse take for a client who lost all possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now."?

Notify the facility chaplain to request scheduling an appointment.

Confirm that everything will be all right because belongings can be replaced.

Identify other housing options and sources of transportation.

Maintain eye contact with the client and summarize the client's feelings.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Notifying the facility chaplain to request scheduling an appointment may be helpful for some clients, but it assumes the client's willingness or desire for spiritual support. It should not be the first action taken without assessing the client's preferences and needs.

Choice B reason:

Confirming that everything will be all right because belongings can be replaced may seem reassuring, but it can also come across as dismissive of the client's emotional distress. Material possessions often have sentimental value, and their loss can be deeply traumatic beyond their monetary worth.

Choice C reason:

Identifying other housing options and sources of transportation is a practical step and may eventually be part of the care plan. However, it should not be the immediate focus when the client is in acute emotional distress and unable to think clearly.

Choice D reason:

Maintaining eye contact with the client and summarizing the client's feelings is an empathetic approach that validates the client's experience. It demonstrates active listening and provides emotional support, which is crucial in the immediate aftermath of a traumatic event.

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Correct Answer is D

Explanation

Choice A reason:

Learned responses can be a predisposing factor for stress. Individuals may develop certain behaviors in response to stressful situations, and these behaviors can become conditioned responses that are triggered in similar future scenarios, potentially leading to stress.

Choice B reason:

Heredity can influence an individual's susceptibility to stress. Genetic factors can determine the sensitivity of one's stress response system, such as the hypothalamic-pituitary-adrenal (HPA) axis, which regulates the body's reaction to stress.

Choice C reason:

Existing conditions, particularly chronic health issues or mental health disorders, can predispose an individual to stress. These conditions can increase the overall burden on the body and mind, making it more difficult to cope with additional stressors.

Choice D reason:

A history of hypotension (low blood pressure) is not typically considered a predisposing factor for stress. While acute stress can temporarily affect blood pressure, a chronic condition like hypotension does not predispose one to experiencing stress.

A. "So, it seems that you feel responsible for what happened to your mother." B. "Your mother will be fine. You shouldn't worry so much." C. "You are not responsible for your mother's stroke, but many people in your situation feel this way." D. "Why do you blame yourself? You could not have prevented the stroke."

Correct Answer is C

Explanation

Choice A reason:

This response acknowledges the son's feelings of responsibility but does not offer comfort or factual reassurance about the nature of cerebrovascular accidents. It's important for the nurse to provide support and correct any misconceptions the family may have about the condition and its causes.

Choice B reason:

While this response attempts to reassure the son, it dismisses his concerns and fails to acknowledge the seriousness of the mother's condition. It's crucial for the nurse to validate the family's feelings and provide realistic information about the patient's health status.

Choice C reason:

This is the most appropriate response because it addresses the son's feelings without assigning blame. It also opens the door for further discussion about stroke, its causes, and the son's feelings, which can be therapeutic. Strokes are often caused by factors beyond anyone's control, such as age, medical history, and genetics, rather than someone's actions or inactions.

Choice D reason:

This response confronts the son's self-blame but may come across as dismissive. It's better to approach such feelings with empathy and provide information that can help the family member understand that strokes can occur unexpectedly and are not typically preventable on a personal level.

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Which of the following actions should the nurse take for a client who lost all possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now."?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing stress. The nurse recognizes which of the following is not a predisposing factor for stress?

Correct Answer is D

Explanation

A nurse is caring for an older adult client diagnosed with a cerebrovascular accident who has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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