A young client diagnosed with major depressive disorder recently had their engagement broken off by their fiancé, who claimed the client was too fat and ugly.

During a one-on-one interaction with the nurse, the client says, “My fiancé is really wonderful and is not to blame for calling off the engagement.

I look awful and I’m not much good for anything.”. What is the most appropriate response by the nurse?

“Tell me how you felt when your fiancé broke up with you.”.

“Maybe the breakup was for the best.”.

“Do you think you are better off without your fiancé?”

“How could your fiancé be wonderful after saying those things to you?”

Answer and Explanation

The Correct Answer is A

Choice A rationale
The nurse’s response, “Tell me how you felt when your fiancé broke up with you,” is the most therapeutic because it encourages the client to express feelings. This is a crucial step in the healing process. The nurse is using active listening skills and showing empathy, which can help build a therapeutic relationship with the client. It’s important for the nurse to provide a safe and nonjudgmental environment for the client to express feelings of sadness, anger, or guilt related to the breakup.
Choice B rationale
The response, “Maybe the breakup was for the best,” is not therapeutic because it minimizes the client’s feelings and experiences. It’s not the nurse’s place to make judgments or assumptions about the situation. The nurse should focus on the client’s feelings and provide support.
Choice C rationale
The response, “Do you think you are better off without your fiancé?” could be seen as leading or suggestive. It’s important for the nurse to remain neutral and not impose personal beliefs or opinions on the client.
Choice D rationale
The response, “How could your fiancé be wonderful after saying those things to you?” could be seen as confrontational and judgmental. It’s not the nurse’s role to judge the client’s relationships or experiences. The nurse should provide a supportive and understanding environment for the client to express feelings.

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Correct Answer is C

Explanation

Choice A rationale
Ideas of reference involve the belief that casual events, people’s remarks, or elements in the environment have a particular and unusual meaning specifically for oneself. This is not what is being described in the question.
Choice B rationale
Perseveration is the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus. It is usually caused by a brain injury or other organic disorder. This is not what is being described in the question.
Choice C rationale
Flight of ideas is a symptom of a thought disorder that causes a rapid shift from one idea to another. This symptom is often seen in conditions like bipolar disorder, particularly during manic episodes. This matches the description given in the question.
Choice D rationale
Confabulation is a memory disturbance in which a person confuses imagined scenarios with actual memories, with no intent to deceive. This is not what is being described in the question.

A. Are you taking any supplements? B. Have you noticed that your skin is dry? C. Have you experienced urgency to urinate? D. Have you noticed the need to urinate less often? .

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

Explanation

Choice A rationale

Supplements can have a significant impact on lab values. For example, taking iron supplements can increase the level of iron in the blood, while taking vitamin D supplements can increase the level of calcium. Therefore, asking the client if they are taking any supplements can provide valuable information that can help interpret the lab results.

Choice B rationale

Dry skin can be a sign of various conditions that can affect lab values. For example, hypothyroidism can cause dry skin and can also cause changes in lab values such as increased TSH (thyroid-stimulating hormone) and decreased T4 (thyroxine)456. Therefore, asking the client if they have noticed that their skin is dry can provide valuable information that can help interpret the lab results.

Choice C rationale

Urgency to urinate can be a sign of various conditions that can affect lab values. For example, a urinary tract infection can cause urgency to urinate and can also cause changes in lab values such as increased white blood cells and bacteria in the urine. Therefore, asking the client if they have experienced urgency to urinate can provide valuable information that can help interpret the lab results.

Choice D rationale

The need to urinate less often can be a sign of various conditions that can affect lab values. For example, dehydration can cause a person to urinate less often and can also cause changes in lab values such as increased blood urea nitrogen (BUN) and creatinine. However, this symptom is not as specific or indicative as the others, and may not provide as much valuable information for interpreting the lab results.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the mental status examination, the nurse observes that the client rapidly shifts from one idea to another related thought. Which disordered thinking process is the client displaying?

Correct Answer is C

Explanation

The practical nurse (PN) reviews the lab values. What Questions can the PN ask the client based on the lab results? Select all that apply.

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

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

During the assessment phase of the nursing process, data collection takes place. What methods does the nurse employ to gather data? (Select all that apply.)

What are the negative symptoms of psychosis?

True or False: Lability is characterized by a rapid change in emotions.

An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?

A recently widowed client is experiencing memory loss, insomnia, loss of appetite, and irritability over the last few months. Which data should the nurse obtain when assessing this client?

The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?