A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic?
"You looked like you would be the most likely to talk back with me."
"Let's go see what activities are going on outside."
"Why shouldn't I talk to you? You looked lonely."
"You're curious why I am interested in you and not the others?"
The Correct Answer is D
A. This response does not address the adolescent's underlying question and may come across as dismissive.
B. This response avoids addressing the adolescent's question and suggests changing the subject.
C. This response is somewhat confrontational and does not explore the adolescent's feelings or concerns.
D. This response acknowledges the adolescent's curiosity and opens the door for further discussion about why the nurse chose to engage with them. It invites the adolescent to explore their feelings and thoughts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. The infant's eyes turn toward the light - This is the expected finding known as the "fixation reflex," where infants naturally turn their eyes toward a light source.
B. The infant's head turns away from the light - This would not be an expected finding during a vision screening; it may suggest a different reflex or issue.
C. The infant's eyes remain focused toward the floor - This would not be an expected finding during a vision screening; it may suggest a different visual or developmental concern.
D. The infant closes their eyes - Closing the eyes in response to light is not the typical response during a vision screening for infants.
Correct Answer is A
Explanation
A.
A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop
the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.
B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.
C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.
D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.
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