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The nurse is interviewing a client who says. "Today is the two-month anniversary of my wife's death from cancer". Select the most therapeutic response by the nurse

A.

"Would you like to discuss this with the doctor?"

B.

"How long were you married?"

C.

"What type of cancer did your wife have?"

D.

"How does that make you feel?"

Answer and Explanation

The Correct Answer is D

A) "Would you like to discuss this with the doctor?": This response may imply that the nurse is not equipped to handle the emotional aspect of the conversation, potentially minimizing the client's feelings and discouraging further sharing.

 

B) "How long were you married?": While this question seeks to gather more information, it does not directly address the client's emotional experience or feelings related to their wife's death, which is the primary concern in this context.

 

C) "What type of cancer did your wife have?": This question may shift the focus to medical details rather than the client's emotional state, which is crucial in a therapeutic conversation about grief and loss.

 

D) "How does that make you feel?": This response is the most therapeutic as it invites the client to express their emotions and thoughts about their loss. It acknowledges their pain and encourages them to explore their feelings, which is essential for processing grief.


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Correct Answer is C

Explanation

A) Notify the healthcare provider that the client is exaggerating their pain: It is inappropriate for the nurse to assume that the client is exaggerating their pain based solely on their demeanor. Pain perception is subjective and can vary greatly among individuals, especially in conditions like sickle cell anemia.

B) Wait 30 minutes and see if the client is still requesting pain medication: Delaying pain relief can lead to unnecessary suffering. Given that the client rates their pain as a 7 out of 10, which indicates significant discomfort, it is essential to address their pain promptly rather than postponing treatment.

C) Administer the pain medication as prescribed: This is the most appropriate action. Clients with sickle cell anemia often experience severe pain crises, and effective pain management is crucial. Administering the medication as prescribed supports the client's comfort and well-being.

D) Administer half of the ordered dose of pain medication: Modifying the dosage without a provider's order is not appropriate. If the full prescribed dose is warranted based on the pain level, the nurse should administer it as indicated to ensure effective pain management.

Correct Answer is C

Explanation

A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.

B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."

C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.

D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.

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