A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night.”. Which of the following responses should the nurse make?

"Lots of people feel ashamed to tell their secrets.”.

"You will feel better if you tell me what you did last night.”.

"Let's discuss what you feel embarrassed about.”.

"You shouldn't feel embarrassed to talk to me.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The response, "Lots of people feel ashamed to tell their secrets," is not the most therapeutic option because it does not directly address the client's need to discuss their feelings or concerns. It does offer some empathy but falls short in terms of encouraging communication and understanding.

Choice B rationale:

The response, "You will feel better if you tell me what you did last night," may come across as too direct and pressuring, which can be counterproductive in building trust with the client. It may make the client feel even more embarrassed or uncomfortable.

Choice D rationale:

The response, "You shouldn't feel embarrassed to talk to me," attempts to reassure the client but may invalidate their feelings and is not as therapeutic as the correct choice. It's important to acknowledge the client's emotions and provide them with a safe space to open up.

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Correct Answer is C

Explanation

A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan? The correct answer is choice C: The client states that she knows she can't be perfect.

Choice A rationale:

The client reports following various cooking blogs. Following cooking blogs does not necessarily indicate adherence to an anorexia nervosa treatment plan. The client might still engage in disordered eating behaviors while having an interest in cooking.

Choice B rationale:

The client's potassium level is 3.2 mEq/L. A potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates electrolyte imbalance. This finding suggests inadequate adherence to the treatment plan, as it may result from continued restrictive eating.

Choice D rationale:

The client's current BMI is 14. A BMI of 14 is significantly below the normal range and is indicative of severe malnutrition. It suggests non-adherence to the treatment plan and ongoing weight loss, which is common in anorexia nervosa.

A. Command hallucinations. B. Impaired memory. C. Inappropriate speech patterns. D. Rapid mood swings.

Correct Answer is A

Explanation

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night.”. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan?

Correct Answer is C

Explanation

A nurse is assessing a client who has delirium.Which of the following findings requires immediate intervention by the nurse?

Correct Answer is A

Explanation

A nurse has placed a client who has become physically aggressive into seclusion.Which of the following actions should the nurse take?

A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.I can't take it anymore.”. Which of the following responses should the nurse make first?

A nurse is assessing a client who recently experienced the loss of their partner.Which of the following questions is the priority for the nurse to ask during this situational crisis?

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

A nurse is caring for a client who has schizophrenia. The client's employer calls to discuss the client's condition. Which of the following is the appropriate nursing action?

A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure.The client informs the nurse that they do not want to have the procedure.Which of the following actions should the nurse take?

A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline.The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?