1) A nurse caring for an adolescent client in the community health center who has a positive (HCG) test.
She tells the nurse, "I don't think I can tell my parents that I am pregnant." Which of the following is an appropriate response?
"You seem frightened to tell your parents."
2) After teaching a client how to perform personal colostomy care prior to discharge. The client says to the nurse, "I don't think that I am going to be able to take care of this myself." Which of the following is an appropriate response by the nurse?
"What part of the colostomy care are you having trouble with?"
3) An ED nurse takes a telephone call from a client who reports "I have just taken 100 amitriptyline (Elavil) tablets to kill myself." The client is crying and says, "I want to die.
I have no reason to live." Which of the following responses by the nurse is appropriate?
"Please stay on the phone with me so we can talk about your feelings."
4) A nurse is caring for an older adult client who dies during the night with his wife at his side. The wife says to the nurse, "I can't believe he's gone." Which of the following is a therapeutic response by the nurse?
"It must be hard to accept that this has happened.
"
5) A nurse is caring for a client with diabetes who is to receive hemodialysis. The client says to the nurse, "I don't even know why I'm doing this. There is no cure." Which of the following is an appropriate nursing response?
A: "It sounds as though you have given up.
"
6) A client with a suspected brain tumor is scheduled for a CAT. When the procedure is explained, the client expresses fear of entering the enclosed space of the scanner. Which of the following responses by the nurse is appropriate?
"Let me review some breathing exercises with you."
7) A client is scheduled for a lumbar puncture to rule out bacterial meningitis and tells the nurse that he is fearful of becoming paralyzed from the needle being place in the spinal column. Which of the following is a therapeutic response by the nurse?
"The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends."
8) A nurse is caring for a client with leukemia.
The client says to the nurse, "The doctor told me that my condition is too severe to be treated successfully, and I am no longer a candidate for chemotherapy. I guess I don't have long to live." Which of the following responses by the nurse is therapeutic?
"Let's talk about how you are feeling about this information."
9) When a nurse is making morning rounds, a client says, "I almost died last night." Which of the following is a therapeutic response by the nurse?
"That must have been frightening for you.
Tell me more about it."
An older adult client is admitted to the hospital for surgery for a fractured hip. The client says to the nurse, "I guess I've lived long enough, and it's my time." Which is the therapeutic response by the nurse?
"You feel that your life is ending?"
An adolescent client is just diagnosed with testicular cancer. When the nurse asks the client a question, he angrily spits in the nurse's face.
Which response by the nurse would be appropriate?
"That behavior makes me very angry, and I will not tolerate it."
An adult child has come to take a parent home from the hospital following a colon resection. The adult child tells the nurse, " I don't know how I am going to take care of my parent now." Which of the following is an appropriate response?
"What part of your parent's care are you concerned about?"
A nursing assistant is caring for a client who is unconscious. While bathing the client, the nursing assistant describes the weather and chats about current events.
The client's wife says to the nurse, "Why does the nursing assistant talk to my husband? He's unconscious.." The nurse should respond by stating,
"Clients like your husband, who are unconscious, may still be able to hear."
A client who has been diagnosed with cancer tells the nurse, "I would rather be dead than go through the treatment for cancer.
"Which of the following is an appropriate response by the nurse?
"What is it about the cancer treatment that concerns you?"
A nurse is caring for a 13 year old is admitted for an emergency appendectomy. While doing the preoperative teaching, the client asks, "Will I have a large scar from the surgery?" Which of the following is an therapeutic response?
"It will be small enough so it wont show when you're wearing a bathing suit."
A nurse is caring for a client following a spontaneous abortion. The client is crying and says to the nurse, "I tried to get pregnant for so long. My husband and I wanted this baby so much. Now what will we do?" Which response by the nurse is to be appropriate?
"Are you feeling overwhelmed?"
When approached by a nurse, a client with major depressive disorder says, "Don't bother me.
Find someone else to talk with. I don't have anything worth saying. Go find someone you can help." Which of the following is a therapeutic response?
"I would like to sit quietly with you for a while.
"
A nurse is assessing a client. For which of the following client statements should the nurse use a close-ended question?
"I'm bleeding."
A nurse is caring for a client who had a spontaneous abortion at 9 weeks of gestation. The nurse walks into the client's room and finds her crying uncontrollably. Which of the following is a therapeutic response?
"It is hard to deal with a pregnancy loss. Here is the number of a local support group that you could attend.
"
A nurse is caring for a client who is a victim of rape. The client says to the nurse, "I feel so humiliated. I don't want anyone to know what happened to me." Which of the following is a therapeutic response?
"Are you saying that you are fearful about what others will think?"
