A nurse is caring for a client who was recently admitted to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?
"I think you should just ignore the others."
"You feel upset by the responses of others."
"Let's keep the focus of our discussion on your needs."
"Everything will get better once you get to know everyone."
The Correct Answer is B
A. Telling the client to ignore others minimizes their feelings and does not address the underlying issue of bullying or social discomfort.
B. Validating the client's feelings acknowledges their emotions and demonstrates empathy, which can help build trust and rapport with the client.
C. While it's important to address the client's needs, dismissing their concerns about social interactions may contribute to feelings of isolation and neglect.
D. Offering reassurance without addressing the client's current distress may invalidate their feelings and overlook the need for support and intervention in the present moment.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.
Correct Answer is A
Explanation
A. Using an adhesive remover can help safely and effectively remove the adhesive residue from the skin without causing irritation or damage.
B. Scrubbing the skin around the colostomy can cause skin irritation and increase the risk of skin breakdown. Gentle cleaning with warm water and mild soap is recommended.
C. Most colostomy bags do not require suctioning of stool, as they are designed to collect fecal matter without the need for suctioning.
D. It is generally recommended to empty the colostomy bag when it is about one-third to one- half full to prevent leakage and maintain skin integrity.
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