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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?".

Answer and Explanation

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.

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Correct Answer is B

Explanation

If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.

Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.

Therefore, the nurse should obtain the respiratory rate first.

Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.

Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.

Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.

A. Have the client demonstrate prescribed wound care. B. Provide written instructions in the client's native language. C. After each instruction, ask the client if he/she understands. D. Have an interpreter repeat the wound care instructions.

Correct Answer is A

Explanation

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

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Which response by the nurse is most therapeutic?

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Naxlex Comprehensive Predictor Exams

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

Correct Answer is B

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Correct Answer is A

Explanation

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The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

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