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 D
Explanation
A. Instilling erythromycin ophthalmic ointment in the newborn's eyes is important to prevent neonatal conjunctivitis, but drying the newborn takes precedence to prevent heat loss and stimulate breathing immediately after birth.
B. Weighing the newborn and placing identification bracelets can be done after drying the newborn.
C. Placing identification bracelets on the newborn is important for identification purposes but does not take precedence over drying the newborn to prevent heat loss and stimulate breathing.
D. Dry the newborn: Drying the newborn is the priority immediately after birth to prevent heat
loss and stimulate breathing. The newborn is wet from amniotic fluid and may be cold due to the temperature difference between the intrauterine and extrauterine environment. Drying the newborn with a warm, soft towel helps to prevent hypothermia and promotes the initiation of breathing, which is essential for oxygenation and lung expansion. This action supports the
newborn's transition to extrauterine life and sets the stage for subsequent assessments and interventions.
Correct Answer is D
Explanation
A. Adjusting the straps on the harness once per week is not recommended. The straps should only be adjusted by a healthcare provider to ensure proper fit and alignment, as incorrect adjustments can compromise the effectiveness of the treatment.
B. Using ultra-thin diapers applied over the straps is incorrect. Diapers should be placed under the harness to prevent soiling and maintain the harness's effectiveness. Placing diapers over the straps can interfere with proper positioning.
C. Maintaining the child in a prone position while the harness is in place is not necessary. The Pavlik harness is designed to keep the hips in a flexed and abducted position, and the infant can remain in various positions that are comfortable and safe.
D. Gently massaging the skin under the straps once per day is correct. This helps prevent skin irritation and promotes circulation. Guardians should also check for redness or irritation and ensure the harness fits properly to avoid pressure injuries.
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