Nokea
While assisting with bathing, the client who has sustained a spinal cord injury states, 'I can't do this. I wish I were dead.' Which therapeutic response should the nurse make to encourage communication?
- A. Why do you say that?
- B. You wish you were dead?
- C. Would you prefer a shower instead?
- D. Are you frustrated with your limitations?
Correct Answer: B
Rationale: Clarifying is a therapeutic technique that involves restating what was said to obtain additional information. By asking 'why' in option 1, the nurse puts the client on the defensive. Option 3 changes the subject. In option 4, false reassurance is offered. The remaining options are nontherapeutic statements that block communication.
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A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.
When planning for the care of the client who is dying of diagnosed cancer, one of the goals is that the client verbalizes her or his acceptance of impending death. Which client statement indicates to the nurse that this goal has been reached?
- A. I just want to live until my 100th birthday.
- B. I would like to have my family here when I die.
- C. I'll be ready to die when my children finish school.
- D. I want to go to my daughter's wedding. Then I'll be ready to die.
Correct Answer: B
Rationale: Acceptance is often characterized by plans for death. Often the client wants loved ones nearby. The remaining options all reflect the bargaining stage of coping during which the client tries to negotiate with her or his higher power or fate.
A prenatal client has been told during a primary health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?
- A. Pain
- B. Nonadherence
- C. Anticipatory grieving
- D. High risk for infection
Correct Answer: C
Rationale: A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem as a result of an inability to achieve life goals. Although the remaining options may be appropriate problem statements, they do not address the information given in the question.
A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, 'I am so afraid my baby is going to die.' Which response by the nurse to the client is best?
- A. Finding out your baby has a serious health problem must be painful.
- B. How does your husband feel about this problem?
- C. How is your baby doing now?
- D. What you need to do is to focus on the present.
Correct Answer: A
Rationale: Acknowledging the client’s pain validates their fear and opens therapeutic communication, supporting emotional processing. Asking about others, focusing on the fetus’s status, or directing focus to the present dismisses the client’s expressed fear.
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels 'as though the rape just happened yesterday.' Which statement is most appropriate for the nurse to use as a response?
- A. In reality, the rape did not just occur. It has been over 2 months now.'
- B. What can you do to alleviate some of your fears about being assaulted again?'
- C. In time, our goal will be to help you move on from these strong feelings about your rape.'
- D. Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.'
Correct Answer: D
Rationale: Option 4 allows for the client to express her ideas and feelings more fully and portrays a unhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe care environment. Although option 1 is true, it immediately blocks communication. Option 2 places the problem-solving totally on the client. Option 3 places the client's feelings on hold.