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 A

Explanation

Choice A reason:Hand hygiene is the foundation of Standard Precautions and the single most effective action to prevent transmission of infectious agents. Performing handwashing or using an alcohol‑based hand rub immediately before preparing or administering an injection removes transient microorganisms acquired from touching surfaces and protects both the client and the environment from contamination

Choice B reason:While wearing gloves during handling and disposal of contaminated sharps is recommended whenever there is potential contact with blood or body fluids, it is a secondary barrier. Reliance on gloves alone is insufficient because gloves can have micro‑perforations and are removed after use, making hand hygiene before and after glove use the priority

Choice C reason: Donning a face mask before administering the medication is not a necessary action to indicate an understanding of standard precautions. A face mask is only required when there is a risk of droplet transmission of infectious agents, such as when caring for a client with respiratory infections. It is not needed for self-administration of medications, unless the medication is aerosolized or nebulized.

Choice D reason: Removing the needle before discarding used syringes is not a safe action to indicate an understanding of standard precautions. It increases the risk of needle-stick injuries and contamination. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

A. Complete an adverse occurrence/incident report. B. Demonstrate proper securing of the restraints. C. Ensure that the restraints are not too tight. D. Initiate the facility's restraint flow sheet.

Correct Answer is B

Explanation

Choice A reason: Completing an adverse occurrence/incident report is not the most important action to implement. It may be necessary to document the incident later, but it does not address the immediate safety issue of the client.

Choice B reason: Demonstrating proper securing of the restraints is the best action to implement. It corrects the mistake made by the UAP and ensures that the client is not at risk of injury or entrapment. It also educates the UAP on the correct technique and policy for applying restraints.

Choice C reason: Ensuring that the restraints are not too tight is a relevant action to implement, but not the most important one. It is part of the ongoing assessment and care of the client who is restrained, but it does not correct the improper securing of the restraints to the bedside rails.

Choice D reason: Initiating the facility's restraint flow sheet is a required action to implement, but not the most important one. It is part of the documentation and evaluation of the client who is restrained, but it does not address the immediate safety issue of the client.

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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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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Correct Answer is A

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

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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?