An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

"You are probably right. Soiling the bed is a way of getting attention from the nursing staff."

"Tell me what makes you feel the client is doing this on purpose?"

"Why don't you spend more time with the client if you think that she is trying to get attention?"

"Next time this happens, tell me and I'll talk to the client about his behavior."

Answer and Explanation

The Correct Answer is B

When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.

Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.

Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.

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Correct Answer is C

Explanation

The parents report that the child injured herself by falling off the couch.

A spiral fracture is a type of broken bone that occurs when a twisting force is applied to the bone. It is often seen in cases of child abuse, where the abuser grabs and twists the child's arm or leg.

Choice A is not correct because bringing the child to the facility soon after the injury does not rule out abuse. The abuser may have done so to avoid suspicion or to prevent further complications.

Choice B is not correct because crying when the arm is examined is a normal reaction for a child who is in pain and scared. It does not indicate abuse or neglect.

Choice C is correct because it is unlikely that a fall from a couch would cause a spiral fracture of the ulna and radius. These bones are strong and require a lot of force to break. A fall from a couch would more likely cause a greenstick fracture, which is a partial break of the bone that occurs in children with flexible bones.

Choice D is not correct because a single injury does not exclude abuse. The child may have been abused before and healed without medical attention, or the abuser may have targeted only one part of the body. A single injury should still raise suspicion and prompt further investigation.

A. Identify the use of defense mechanisms. B. Prevent the client from harming herself or others. C. Support the client's coping skills.

Correct Answer is B

Explanation

Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.

Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.

Choice C, supporting the client's coping skills, is not a priority intervention.

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An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which of the following findings should the nurse recognize as a potential indication of abuse?

Correct Answer is C

Explanation

A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)

The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?

A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse. Which of the following comorbidities should the nurse include in the discussion? (Select all that apply.)

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?