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?

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

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

"What did you enjoy about your visit tonight?"

"I can see that you are feeling lonely."

None

Answer and Explanation

The Correct Answer is A

Choice A reason: This option is the most therapeutic because it is open-ended and invites the client to express feelings and experiences about the visit. By encouraging the client to talk, the nurse provides an opportunity for the client to explore emotions, which could explain why they became isolative afterward. Open-ended questions also demonstrate interest and support, which fosters trust and promotes communication in therapeutic relationships.

Choice B reason: Asking if the client would like to talk is supportive, but it is too vague and closed-ended. The client may simply answer “yes” or “no,” which does not facilitate deeper exploration of feelings. While it offers availability, it is not as therapeutic as directly encouraging discussion about the observed event, the visit.

Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

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Correct Answer is B

Explanation

Choice A reason: Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.

Choice B reason: Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.

Choice C reason: Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.

Choice D reason: Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.

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

Correct Answer is A

Explanation

Choice A reason: This is the correct action because the nurse should obtain the specimen as soon as possible to avoid delays in diagnosis and treatment. The color and consistency of the stool do not affect the test for occult blood.

Choice B reason: This is not necessary because the nurse does not need to obtain a prescription or approval from the healthcare provider to collect a stool specimen for occult blood. The nurse should follow the standard protocol for specimen collection and labeling.

Choice C reason: This is incorrect because withholding specimen collection until tarry black stool is observed would delay the detection of occult blood. Tarry black stool indicates a bleeding source in the upper gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

Choice D reason: This is also incorrect because waiting to obtain the specimen until observable blood is present would also delay the detection of occult blood. Observable blood indicates a bleeding source in the lower gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

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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

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Correct Answer is B

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 A

Explanation

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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?

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