Which response by the nurse is most therapeutic?
"Tell me about the visit with your significant other.".
"I can see that you are feeling lonely.".
"Would you like to talk for a while?".
"What did you enjoy about your visit tonight?".
The Correct Answer is C
This response shows that the nurse is willing to listen and provide support to the client.
It also allows the client to decide if they want to talk and share their feelings.
Choice A is not correct because it is not the most therapeutic response.
While it does encourage the client to talk about their visit with their significant other, it does not show that the nurse is willing to listen and provide support.
Choice B is not correct because it is not the most therapeutic response.
While it does acknowledge that the client may be feeling lonely, it does not show that the nurse is willing to listen and provide support.
Choice D is not correct because it is not the most therapeutic response.
While it does encourage the client to talk about their visit, it does not show that the nurse is willing to listen and provide support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.
Correct Answer is B
Explanation
A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.
B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.
C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.
D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.
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