Ms. S is admitted to your medical unit with a diagnosis of dehydration and a history of depression. She tells you, "I just can't eat, I'm not hungry." What would be your best therapeutic response?

"You aren't hungry?"

"If you can't eat, what is that candy bar wrapper doing under your bed?"

"You really should try to eat some real food."

"Why aren't you hungry?"

Answer and Explanation

The Correct Answer is D

Choice A reason: This response is a closed-ended question that might not encourage further discussion or reveal the underlying issues.

Choice B reason: This confrontational approach could make the patient defensive and is not conducive to building a therapeutic relationship.

Choice C reason: While encouraging the patient to eat is important, this directive does not address the patient's feelings or concerns.

Choice D reason: Asking an open-ended question invites the patient to share more about their feelings and can lead to a better understanding of their lack of appetite.

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Correct Answer is A

Explanation

Choice A reason:Monitoring the apical pulse helps ensure safety and effectiveness of digoxin therapy.

Choice B reason:Offering a light snack is not relevant to digoxin administration.

Choice C reason:While checking the client's blood pressure is important, it is not directly related to digoxin administration.

Choice D reason:Weighing the client is not a specific action related to digoxin administration.

A. The client is hostile and sarcastic towards the staff. B. The client gives personal items and money away to other clients. C. The client paces in the hallway during the day and most of the night. D. The client demonstrates flight of ideas.

Correct Answer is C

Explanation

Choice A reason: While hostility and sarcasm can be challenging, they are not immediate safety concerns compared to the physical activity that could lead to exhaustion or injury.

Choice B reason: Giving away personal items and money can be concerning for the client's financial well-being, but it does not pose an immediate risk to their physical health.

Choice C reason: Pacing in the hallway during the day and most of the night could indicate a high level of psychomotor agitation associated with mania, which can lead to physical exhaustion or injury and is therefore a priority.

Choice D reason: Flight of ideas is a symptom of mania that, while important to note, does not pose an immediate risk to the client's safety like excessive physical activity does.

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Ms. S is admitted to your medical unit with a diagnosis of dehydration and a history of depression. She tells you, "I just can't eat, I'm not hungry." What would be your best therapeutic response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a client who has heart failure. Before administering this medication, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has a new diagnosis of angina pectoris. Which of the following information about anginal pain should the nurse include in the teaching?

Your patient has a diagnosis of major depressive disorder and has been started on sertraline (Zoloft) 50mg daily. After taking the medication for 3 days, the patient says, "I don't think the medicine is working. I don't want to take it any longer." What is your best response?

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

The nurse would evaluate a female patient, age 68, as understanding teaching on the purpose of coronary artery bypass graft surgery if she made which of the following statements?

Your patient, who is manic, says, "Everything I do is great." How should you respond?

The nursing interventions for a patient with major depression would include all the following except:

Your patient with major depressive disorder isolates herself in her room for the whole day. You find her sitting and staring out the window. What is your best therapeutic response when you walk into her room?

The nurse who is assessing a patient with major depression would expect to observe which of the following symptoms?