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 D

Explanation

Choice A Reason:

“There is no such thing as the devil. It’s all in your mind.”

This response dismisses the client’s experience and can make them feel invalidated. Telling the client that their experience is “all in your mind” does not acknowledge their distress and can increase their feelings of isolation and mistrust. It is important to validate the client’s feelings while gently orienting them to reality.

Choice B Reason:

“You are not going to hell. You are a good person.”

While this response is supportive, it does not address the client’s immediate distress about hearing voices. It is important to acknowledge the client’s experience of hearing voices and provide reassurance in a way that helps them feel understood and supported. Simply telling them they are a good person may not alleviate their anxiety about the voices.

Choice C Reason:

“Did you take your medicine this morning?”

Asking about medication adherence is important, but it is not the most appropriate immediate response to the client’s distress. This question can come across as dismissive and may not provide the immediate comfort and validation the client needs. It is better to first acknowledge the client’s experience and then address medication adherence later.

Choice D Reason:

“The voices sound distressing, but I don’t hear them.”

This is the correct response. It acknowledges the client’s distress and validates their experience without reinforcing the delusion. By stating that the nurse does not hear the voices, it gently orients the client to reality while showing empathy and understanding. This approach helps build trust and provides comfort to the client.

Correct Answer is ["0.5"]

Explanation

Step 1: Identify the available concentration of fentanyl.

The ampule contains 100 micrograms of fentanyl in 2 mL.

Step 2: Determine the dose required.

The nurse needs to give 25 micrograms of fentanyl.

Step 3: Calculate the volume (mL) needed for the required dose.

Use the formula: (Dose required ÷ Dose available) × Volume of available dose.

Step 4: Substitute the values into the formula.

(25 micrograms ÷ 100 micrograms) × 2 mL

Step 5: Perform the division.

25 micrograms ÷ 100 micrograms = 0.25

Step 6: Perform the multiplication.

0.25 × 2 mL = 0.5 mL

Result: The nurse will give 0.5 mL for the correct dose.

Final Answer: 0.5 mL

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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 with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

Correct Answer is D

Explanation

The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

Correct Answer is ["0.5"]

Explanation

The nurse recognizes that a function of the Mental Status Exam is to:

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