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
None
The Correct Answer is A
Choice A reason: This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.
Choice B reason: This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Paper mask and gown are considered regulated medical waste, which means they are contaminated with blood, body fluids, or microorganisms that pose a potential risk of infection¹. Therefore, they should be placed in a designated biohazard bag before they are removed from the room and treated according to the facility's policies and procedures².
Choice B reason: The nurse's stethoscope is not a disposable item and does not need to be placed in a biohazard bag. However, it should be cleaned and disinfected after each use to prevent cross-contamination³.
Choice C reason: Bed linens are not classified as regulated medical waste unless they are soaked with blood or body fluids¹. They can be placed in a regular laundry bag and washed according to the facility's guidelines.
Choice D reason: Sputum specimen is a type of microbiology laboratory waste, which is regulated medical waste¹. However, it should not be placed in a biohazard bag, but in a leak-proof, puncture-resistant container that is labeled with a biohazard symbol. This ensures the safe transport and handling of the specimen.
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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