The nurse is bathing a client when the client begins to cry. Which act

Caring for a Patient

Home / Nursing & Allied Health Certifications / NCLEX RN / Nursing Process

Question 1 of 5.

The nurse is bathing a client when the client begins to cry. Which action by the nurse is therapeutic at this time?

A. Continue bathing the client and say nothing.

B. Stop the bath, cover the client, and sit with the client.

C. Stop the bath, cover the client, and allow the client private time.

D. Call the primary health care provider to report the signs of depression.

Explanation: If a client begins to cry, the nurse should stay with the client and let the client know that it is all right to cry. The nurse should ask the client what the client is thinking or feeling at the time. By continuing the bath or by leaving the client, the nurse appears to be ignoring the client's feelings. Crying alone is not necessarily an indication of depression, and calling the primary health care provider is a premature action.

Question 2 of 5.

A client diagnosed with diabetes mellitus requires the immediate amputation of a leg. The client is very upset and states, 'This is the doctor's fault! I did everything that I was told to do!' When considering the grieving process, how should the nurse respond to the client's statement?

A. Notify the agency's risk management department.

B. Help the client consider alternatives to treatment.

C. Allow the client to use anger as a coping mechanism.

D. Ask the client to list all previous health care providers.

Explanation: Anger is a stage in the grieving process and an expected response to impending loss. Usually a client directs the anger toward himself or herself, God or another spiritual being, or the caregivers; thus far the client's behavior demonstrates effective coping. Notifying the risk management department is premature, especially because the client has said nothing about legal action. Analyzing alternative treatment options and previous health care providers is likely to interfere with effective coping, and it can delay lifesaving treatment.

Question 3 of 5.

The nurse has an established relationship with the family of a client whose death is imminent. Which intervention should the nurse focus on in order to help the family most effectively cope with this experience?

A. Limiting time in the client's room to promote privacy

B. Providing education regarding coping mechanisms to use

C. Identifying spiritual measures that work best for dying clients

D. Answering questions clearly and providing resources as requested

Explanation: Maintaining effective and open communication among family members affected by death and grief is important to facilitate decision making and effective coping. The nurse maintains and enhances communication and preserves the family's sense of self-direction and control effectively by answering questions clearly and providing information and resources for decision making as requested by the family. Isolating the family from the client by limiting time in the client's room is inappropriate. The nurse should not provide education about coping mechanisms for family members to use because coping mechanisms directed by the nurse are unlikely to be as effective as the methods that the individuals choose for themselves. Identifying spiritual measures that work best for the dying client generalizes and does not reflect individualized care.

Question 4 of 5.

A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time?

A. Remaining with the client

B. Placing the client in a quiet room

C. Teaching the client deep-breathing exercises

D. Encouraging the expression of feelings and concerns

Explanation: If the client is left alone with severe anxiety, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.

Question 5 of 5.

When a client is dead on arrival (DOA) to the emergency department, the family states that they do not want an autopsy performed. Which statement should the nurse make in response to the family?

A. Autopsies are mandatory for clients who are DOA.'

B. Federal law requires autopsies for clients who are DOA.'

C. The medical examiner makes the decision about autopsies.'

D. I will make sure the medical examiner is aware of your request.'

Explanation: The nurse should notify the medical examiner or the coroner when a family wishes to avoid having an autopsy on a deceased family member. Normally the medical examiner will honor the family request unless there is a state law requiring the autopsy. Depending on the state, it is not mandatory for every client who is DOA to have an autopsy. However, many states require an autopsy in specific circumstances, including sudden death, a suspicious death, and death within 24 hours of admission to the hospital. Autopsy is not a requirement under federal law.