A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

I may consider dating you once you have fully recovered.

It’s against hospital policy for me to date clients.

This is a professional relationship, and we need to be clear on that.

I’m sorry, but I’m married and not interested in dating.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

This response is inappropriate as it blurs the professional boundaries between the nurse and the client. Nurses are expected to maintain a professional relationship with their clients to ensure that care is provided in an ethical and unbiased manner. Suggesting a potential future relationship can lead to misunderstandings and compromise the therapeutic relationship.

Choice B Reason:

While this response correctly states hospital policy, it does not address the underlying issue of maintaining professional boundaries. It is important for the nurse to communicate the need for a professional relationship clearly and directly. Simply citing policy may not fully convey the importance of these boundaries to the client.

Choice C Reason:

This response is the most appropriate because it clearly establishes the professional nature of the nurse-client relationship. It helps the client understand that the nurse’s role is to provide care and support within a professional framework. This clarity is essential for maintaining trust and ensuring that the therapeutic relationship remains effective and ethical.

Choice D Reason:

Although this response sets a personal boundary, it does not address the professional aspect of the nurse-client relationship. The nurse’s marital status is irrelevant to the professional boundaries that need to be maintained. It is more important to emphasize the professional nature of the relationship rather than personal reasons for declining the request.

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Correct Answer is A

Explanation

Choice A Reason:

Clozapine is known to cause agranulocytosis, a potentially life-threatening condition where the white blood cell count drops significantly, leading to a higher risk of infection. Patients on clozapine must have regular blood tests to monitor their white blood cell count. Any signs of infection, such as fever, sore throat, or flu-like symptoms, should be reported to a physician immediately as they could indicate agranulocytosis.

Choice B Reason:

A decrease in hallucinations is generally a positive sign indicating that the medication is working effectively. It is not a reason to call the physician immediately. Instead, this should be discussed during regular follow-up appointments to assess the overall effectiveness of the treatment.

Choice C Reason:

While a decrease in appetite can be a side effect of clozapine, it is not typically an emergency unless it leads to significant weight loss or malnutrition. This should be monitored and discussed with the physician during regular visits. If the decrease in appetite is severe or persistent, it may warrant a call to the physician, but it is not as urgent as signs of infection.

Choice D Reason:

Insomnia can occur with clozapine use, but it is usually managed with adjustments to the medication regimen or additional treatments for sleep. While it is important to address insomnia, it does not require immediate medical attention unless it severely impacts the patient’s well-being.

A. Documentation of the event will include interventions attempted prior to initiating restraints. B. The physician must be present at the time of the restraint episode. C. The client will be turned every 2 hours. D. The client will need to be monitored every one-half hour.

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

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A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

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Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:

Correct Answer is A

Explanation

When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Correct Answer is ["A","C","D"]

Explanation

An IV infusion of 125 mL of a GI prokinetic agent is ordered to be given over 1 hour. The nurse will use a microdrip infusion set (60 gtts/mL). How many drops per minute will the drug infuse at the proper rate? Use a preceding zero if necessary. Do not use trailing zeros.

A client diagnosed with Obsessive-Compulsive Disorder has developed a number of compulsive washing rituals over the years. The nurse recognizes that these behavioral rituals serve which purpose?

A client is admitted to an inpatient unit with a diagnosis of frontotemporal dementia. Which of the following aspects of a medical history would the nurse expect to see with this client? (Select All that Apply.)

A client is admitted to the Emergency Department (ED) after ingesting a large amount of diazepam. Which medication would the nurse expect the ED physician to order?

A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?

After being in the hospital for one month, a client with schizophrenia states that voices are telling them they will die tonight. The client asks the nurse if this is true. The client’s statement and question indicate that they:

A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?