A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?
"Would you like to talk for a little while?"
"I can see that you are feeling lonely."
"Tell me about the visit with your significant other."
"What did you enjoy about your visit tonight?"
The Correct Answer is A
Choice A Reason: This is correct because this response invites the client to express her feelings and thoughts without imposing any assumptions or judgments. It also conveys empathy and respect for the client's autonomy.
Choice B Reason: This is incorrect because this response makes an inference about the client's emotional state without validating it with her. It also may sound patronizing or pitying, which can hinder rapport.
Choice C Reason: This is incorrect because this response may be perceived as intrusive or prying, especially if the client is not ready or willing to share details about her personal relationship. It also may trigger negative emotions or memories that can worsen her mood.
Choice D Reason: This is incorrect because this response may be seen as superficial or irrelevant, especially if the client did not enjoy her visit or had a conflict with her significant other. It also may imply that the nurse is avoiding or dismissing the client's current feelings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.
Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.
Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.
Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a sputum specimen should be placed in a sealed container and labeled with the client's name, date, and time before it is removed from the room. The container should be transported to the laboratory in a plastic bag.
Choice B Reason: This is incorrect because bed linens should be placed in a leak-proof laundry bag and handled with minimal agitation before they are removed from the room. The laundry bag should be closed securely and transported to the laundry facility.
Choice C Reason: This is incorrect because the nurse's stethoscope should be cleaned and disinfected with an alcohol wipe or a germicidal solution before it is removed from the room. The stethoscope should not be shared with other clients or staff.
Choice D Reason: This is correct because paper mask and gown are disposable items that are contaminated with the client's respiratory secretions and body fluids. They should be placed in a designated biohazard bag and disposed of properly before they are removed from the room.
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