A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

"Would you like to talk for a little while?"

"I can see that you are feeling lonely."

"Tell me about the visit with your significant other."

"What did you enjoy about your visit tonight?"

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because this response invites the client to express her feelings and thoughts without imposing any assumptions or judgments. It also conveys empathy and respect for the client's autonomy.

Choice B Reason: This is incorrect because this response makes an inference about the client's emotional state without validating it with her. It also may sound patronizing or pitying, which can hinder rapport.

Choice C Reason: This is incorrect because this response may be perceived as intrusive or prying, especially if the client is not ready or willing to share details about her personal relationship. It also may trigger negative emotions or memories that can worsen her mood.

Choice D Reason: This is incorrect because this response may be seen as superficial or irrelevant, especially if the client did not enjoy her visit or had a conflict with her significant other. It also may imply that the nurse is avoiding or dismissing the client's current feelings.

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Correct Answer is D

Explanation

Choice A: Remind the UAP to dry between the client’s toes completely is not the best action because it does not address the risk of spillage and wetness on the bed. Drying between the toes is important to prevent fungal infections, but it can be done after removing the basin.

Choice B: Advise the UAP that this procedure is damaging to the skin is not the best action because it is not accurate and may cause confusion. Soaking the foot in warm water is not harmful to the skin, unless it is too hot or too long.

Choice C: Add skin cream to the basin of water while the foot is soaking is not the best action because it does not solve the problem and may waste the cream. Skin cream should be applied after drying the foot, not mixed with water.

Choice D: Remove the basin of water from the client’s bed immediately is the best action because it prevents potential hazards such as soaking, infection, or electric shock. The nurse should ensure that the bed is dry and clean before continuing with the bath.

A. Wait to obtain the specimen until observable blood is present. B. Withhold specimen collection until tarry black stool is observed. C. Obtain the specimen from the client's current bowel movement. D. Contact the healthcare provider before obtaining the specimen.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.

Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.

Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.

Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.

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A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?

Correct Answer is D

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is C

Explanation

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

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The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

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A client who had a cerebral vascular accident (CVA) and is at risk for aspiration is being fed by an unlicensed assistive personnel (UAP). Which action by the UAP should the nurse recognize indicates the need for additional teaching?

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?