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

The correct answer is: d. Perform oropharyngeal suctioning.

Choice A: Irrigate the nasogastric tube with water

Reason: Irrigating the nasogastric tube with water is not appropriate when a client is choking and vomiting. This action could potentially worsen the situation by introducing more fluid into the stomach, increasing the risk of aspiration.

Choice B: Review the advance directive document

Reason: Reviewing the advance directive document is not an immediate action to take when a client is choking. Advance directives provide guidance on the client’s wishes for medical treatment but do not address acute emergency interventions.

Choice C: Elevate the head of bed 45 degrees

Reason: Elevating the head of the bed to 45 degrees can help reduce the risk of aspiration by using gravity to keep stomach contents down. However, this action alone is not sufficient to address the immediate choking hazard.

Choice D: Perform oropharyngeal suctioning

Reason: Performing oropharyngeal suctioning is the correct action because it directly addresses the choking hazard by clearing the airway of vomit and other obstructions. This is a critical step to ensure the client’s airway is clear and they can breathe properly.

A. Provides comfort, dignity, and emotional support. B. Can be provided within comforts of home. C. Hospice services can be initiated prior to discharge. D. Family members can be involved in the plan of care. E. A living will becomes invalid when receiving hospice care.

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

Explanation

Choice A Reason: This is correct because hospice provides comfort, dignity, and emotional support to clients with terminal illnesses and their families. Hospice focuses on palliative care rather than curative treatment.

Choice B Reason: This is correct because hospice can be provided within comforts of home or in other settings such as nursing homes or hospice facilities. Hospice allows clients to die in their preferred environment.

Choice C Reason: This is correct because hospice services can be initiated prior to discharge from the hospital or at any time during the course of the illness. Hospice requires a physician's order and a prognosis of six months or less to live.

Choice D Reason: This is correct because family members can be involved in the plan of care and receive education, counseling, and bereavement support from hospice staff. Hospice promotes family-centered care and respects cultural and spiritual preferences.

Choice E Reason: This is incorrect because a living will remains valid when receiving hospice care. A living will is a legal document that expresses the client's wishes regarding life-sustaining treatments in case of incapacity.

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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

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is D

Explanation

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? (Select all that apply.)

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

Explanation

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