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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?"

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Early decelerations are typically benign and occur due to head compression during

contractions. They mirror the uterine contraction pattern and are not usually associated with fetal compromise.

B. Fetal hypoxia is not typically associated with early decelerations, as they are considered a normal response to head compression during labor.

C. Abruptio placentae refers to the premature separation of the placenta from the uterine wall and is not directly related to early decelerations.

D. Postmaturity refers to a pregnancy that extends beyond 42 weeks gestation and is not directly related to early decelerations.

A. Take the client to the bathroom to void. B. Ask the client to verify the surgical site. C. Review deep breathing and coughing exercises. D. Raise the side rails on the bed.

Correct Answer is D

Explanation

A. Taking the client to the bathroom after administering a preoperative sedative increases the risk of falls.
B. Surgical site verification should be completed before administering the preoperative medication.
C. Teaching should be done before giving the medication, as the sedative may impair learning and recall.
D. Raising the side rails helps ensure client safety by preventing falls after the medication has been administered.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?

Correct Answer is A

Explanation

A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?

A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following Instructions should the nurse include?

A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?

A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following?

A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?