A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes.

“Why are you interested in seeing your therapist’s notes?”.

“I don’t think you will benefit from reviewing your therapist’s notes right now.”.

“Are you not happy with your treatment?”.

“We can provide a copy of your records, but the therapist’s notes are not included.”.

Answer and Explanation

The Correct Answer is D

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Correct Answer is ["B","C","D"]

Explanation

The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.

These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.

Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.

The nurse should provide a structured and consistent daily routine for the client.

Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.

The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.

A. Observe the position of the suspended weight B. Check the client’s pedal pulse on the right leg C. Ask the client to describe her pain D. Remind the client to use the incentive spirometer E. None F. None

Correct Answer is D

Explanation

The correct answer is D. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.

Choice C rationale:

Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.

Choice D rationale:

Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.

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A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).

Correct Answer is ["B","C","D"]

Explanation

A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

A nurse is reviewing a client’s cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying

A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching?

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?