A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed wearing clean clothes, and styled hair. Which of the following responses by the nurse is therapeutic?

"Why are you all dressed up today?”

“I see you have done some grooming today"

“Everyone feels better after showering”

"You must be getting better. You look great”

Answer and Explanation

The Correct Answer is B

This response acknowledges the client's effort and self-care without making assumptions or imposing judgment. It is an open and non-intrusive statement that shows the nurse is paying attention to the client's appearance and recognizing their positive action of self-grooming. It allows the client to share their feelings or thoughts if they choose to without feeling pressured or judged. This response demonstrates empathy and understanding, creating a supportive and non-threatening environment for the client to express themselves if they wish to do so.

Incorrect:

A- "Why are you all dressed up today?" This question may put the client on the spot and make them feel self-conscious or defensive. It assumes that there must be a specific reason for the client's appearance, which may not be the case. It can also imply that the client's usual appearance is different or not as desirable.

C- "Everyone feels better after showering." While it is true that personal hygiene can have a positive impact on one's mood, this statement may come across as dismissive or oversimplifying the client's experience. It may invalidate any underlying emotions or struggles the client is facing with their depression. It is important to acknowledge and address the client's feelings rather than making broad generalizations.

D- "You must be getting better. You look great." This statement assumes that physical appearance is directly correlated with the client's mental health and suggests that improvement in appearance equates to improvement in mental well-being. However, a person's outward appearance may not accurately reflect their internal struggles or progress in managing depression. Additionally, it can create pressure for the client to maintain a certain appearance to be perceived as "better."

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Correct Answer is C

Explanation

Obtaining informed consent is a crucial step before administering electroconvulsive therapy (ECT). Informed consent ensures that the client is fully informed about the procedure, its potential risks and benefits, and any alternative treatments available. It allows the client to make an autonomous decision regarding their treatment.

The other responses are not accurate:

A- "ECT is an effective treatment for personality disorders." While ECT may be used in certain cases of severe mental illness, it is not primarily indicated for personality disorders.

B- "It is a myth that clients experience seizures during ECT." Seizures are a common and expected effect of ECT. ECT involves the induction of controlled seizures under anesthesia.

D- "Should monitor the client closely for hypotension following ECT." While monitoring the client for various physiological changes is important, hypotension is not a primary concern following ECT. The nurse would typically monitor for potential adverse effects such as confusion, memory loss, headache, and muscle soreness.

A. Hypothermia B. Hypotension C. Tremors D. Respiratory depression

Correct Answer is C

Explanation

Tremors: This choice is correct. Tremors or muscle twitching can be expected in a client experiencing acute cocaine toxicity. Cocaine is a central nervous system stimulant that can cause overstimulation of muscles, resulting in tremors.

Incorrect:

A- Hypothermia: This choice is incorrect. Acute cocaine toxicity is associated with an increase in body temperature (hyperthermia) rather than a decrease (hypothermia). Cocaine is a stimulant that can cause the body to overheat, leading to hyperthermia, which is a dangerous condition that requires immediate medical attention.

B- Hypotension: This choice is incorrect. Cocaine is a stimulant that increases blood pressure and heart rate, leading to hypertension (high blood pressure), not hypotension (low blood pressure). Hypertension is a common cardiovascular effect of cocaine use.

D- Respiratory depression: This choice is incorrect. Respiratory depression, which is a slowing of the respiratory rate and depth, is more commonly associated with depressant drugs like opioids or benzodiazepines. As a stimulant, cocaine tends to have the opposite effect, leading to increased respiratory rate (tachypnea) and sometimes hyperventilation.

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A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed wearing clean clothes, and styled hair. Which of the following responses by the nurse is therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who is experiencing acute cocaine toxicity. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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