The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
Gives the client a hug and says, “It is okay to cry when you are sad.”.
“I am sorry to disturb you at a difficult time. This can wait until later.”.
While touching the client’s forearm, asks, “Would you like to talk about it?”
“This is a bad time.I can see you are upset. I can come back later.”. .
The Correct Answer is C
Choice A rationale
Giving the client a hug and saying, “It is okay to cry when you are sad,” may be comforting, but it may also be seen as intrusive and not respecting the client’s personal space. Physical touch should be used cautiously and only when the nurse is certain that it is welcome and appropriate. Additionally, this response does not encourage the client to express their feelings or provide an opportunity for the nurse to understand the underlying cause of the client’s distress.
Choice B rationale
Saying, “I am sorry to disturb you at a difficult time. This can wait until later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.
Choice C rationale
While touching the client’s forearm, asking, “Would you like to talk about it?” is the best response as it shows empathy and offers the client an opportunity to express their feelings. This response respects the client’s personal space while also providing a gentle touch that can be comforting. It opens the door for communication and allows the nurse to provide emotional support and address any concerns the client may have.
Choice D rationale
Saying, “This is a bad time. I can see you are upset. I can come back later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.
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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Determining the elasticity of the client’s skin turgor is not directly related to nasopharyngeal suctioning. Skin turgor assessment is typically used to evaluate hydration status and does not provide information about the respiratory status or the need for suctioning.
Choice B rationale
Auscultating the bowel sounds in all four quadrants is unrelated to nasopharyngeal suctioning. Bowel sounds assessment is important for gastrointestinal evaluation but does not help in assessing the respiratory status or the effectiveness of suctioning.
Choice C rationale
Palpating the client’s pedal pulse volume bilaterally is not relevant to nasopharyngeal suctioning. This assessment is used to evaluate peripheral circulation and does not provide information about the respiratory status or the need for suctioning.
Choice D rationale
Observing the client’s skin and mucous membranes is crucial during nasopharyngeal suctioning. This assessment helps determine the client’s oxygenation status and the presence of cyanosis, which can indicate hypoxia. It also helps in identifying any trauma or irritation caused by the suctioning procedure.
Correct Answer is A
Explanation
Choice A rationale
Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.
Choice B rationale
Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.
Choice C rationale
Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.
Choice D rationale
Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.