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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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Brushing teeth immediately after eating may exacerbate nausea, especially if the client is experiencing pregnancy-related nausea and vomiting.

B. Laying down for 30 minutes after meals may worsen nausea and reflux symptoms.

C. Drinking 12 oz of water with each meal may contribute to feelings of fullness and exacerbate nausea and vomiting.

D. Eating a dry carbohydrate before getting out of bed, such as crackers or dry toast, can help alleviate nausea and vomiting associated with pregnancy by providing a bland, easily digestible source of energy before the client starts moving in the morning.

A. Auscultate the client's left arm for a bruit every 4 hours. B. Compare blood pressure in both arms every 2 hours. C. Instruct the client to keep the left arm in a dependent position. D. Encourage the client to restrict movement of the left arm.

Correct Answer is A

Explanation

A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.

B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.

C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.

D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following Instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?

A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder?

A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is: