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 B
Explanation
A. Apply oxygen at 3 L/min per nasal cannula: While oxygenation is important, there is no
indication in the scenario that the client requires oxygen supplementation at this time. Checking oxygen saturation would be more relevant if there were respiratory concerns.
B. Review the chest x-ray report: This is the most appropriate action before initiating the IV
infusion to ensure proper placement of the central venous catheter and absence of complications such as pneumothorax or malposition.
C. Flush the catheter with sterile water: Flushing the catheter with sterile water is not necessary before starting the infusion, especially without confirming proper catheter placement through chest x-ray.
D. Obtain a peripheral blood glucose level: While monitoring blood glucose levels may be
important in certain clinical situations, it is not directly relevant to initiating an IV infusion of Ringer's lactate via a central venous catheter.
Correct Answer is D
Explanation
A. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.
B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.
C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.
D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.
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