A nurse is assisting in the care of an adolescent who states, "I hate living at home. It's impossible to please my parents." Which of the following responses should the nurse make?

"Your parents care for you and want what's best for you."

"Let's talk about your relationship with your parents."

"Why do you think your parents are hard to please?"

"Things will get better as time goes on."

Answer and Explanation

The Correct Answer is B

Choice A reason: While this statement might be true, it can come across as dismissive or invalidating the adolescent's feelings. The nurse's goal should be to listen and understand the adolescent's perspective, rather than making assumptions about the parents' intentions.

Choice B reason: This response opens up a conversation about the adolescent's feelings and experiences regarding their relationship with their parents. It shows empathy and a willingness to understand the adolescent's perspective, which can help build trust and rapport. By exploring the relationship, the nurse can gather more information and provide appropriate support and guidance.

Choice C reason: Asking "Why do you think your parents are hard to please?" can come across as confrontational or judgmental. It might make the adolescent feel defensive or misunderstood. The nurse should focus on creating a supportive environment for the adolescent to express their feelings without feeling judged.

Choice D reason: Telling the adolescent that "Things will get better as time goes on" can seem dismissive and may not address the immediate concerns and feelings the adolescent is experiencing. It is important for the nurse to validate the adolescent's feelings and offer support and understanding in the present moment.

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Correct Answer is C

Explanation

Choice A reason: Hypoactive bowel sounds can indicate a variety of gastrointestinal issues, but they are not typically associated with haloperidol use. While it is important to monitor bowel sounds, it is not the priority in this context.

Choice B reason: Dry mouth is a common side effect of many medications, including haloperidol. While it can be uncomfortable for the client, it is not usually a serious concern and can be managed with hydration and other supportive measures.

Choice C reason: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.

Choice D reason: Photosensitivity is not a common side effect of haloperidol. While it is important to monitor for any new or unusual symptoms, photosensitivity is not typically associated with this medication.

A. "You have the right to refuse medications prescribed during your stay." B. "Your admission status allows you to leave the facility at any time." C. "Your health care team will review your admission status in 90 days." D. "You will automatically have a legal guardian appointed during this admission." E. The correct answer is: a) "You have the right to refuse medications prescribed during your stay."

Correct Answer is A

Explanation

Choice A reason: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.

Choice B reason: This statement is incorrect because involuntary admission means that the client cannot leave the facility at any time. Involuntary admission is typically initiated because the client is unable to meet their own physical needs or poses a danger to themselves or others. Therefore, their ability to leave the facility is restricted until their condition improves or their admission status is reviewed and changed.

Choice C reason: This statement is misleading because the review of admission status for involuntary patients usually occurs much sooner than 90 days. Legal requirements and procedures for reviewing involuntary admission status vary by jurisdiction, but typically, initial reviews occur within a few days to weeks to ensure that the client's rights are protected and that continued hospitalization is necessary.

Choice D reason: This statement is incorrect. Involuntary admission does not automatically result in the appointment of a legal guardian. The process of appointing a legal guardian is separate and involves a legal proceeding where a court determines the need for guardianship. The involuntary admission process is primarily focused on the immediate care and safety of the client.

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A nurse is assisting in the care of an adolescent who states, "I hate living at home. It's impossible to please my parents." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?

Correct Answer is C

Explanation

A nurse is assisting with the involuntary admission of a client who has an anxiety disorder and is unable to meet their basic physical needs. Which of the following statements should the nurse make to the client?

Correct Answer is A

Explanation

A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?

A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

A nurse is reinforcing teaching with a client about naltrexone. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?

A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?

A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?

A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?

A nurse is discussing the care of a client who has alcohol use disorder with another nurse. Which of the following statements should the nurse identify as an indication of countertransference?