A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

"You are making progress in your treatment plan."

"You should call your partner to discuss this."

"It must be very frustrating for you to be here."

"It would be best to discuss your feelings with your provider."

Answer and Explanation

The Correct Answer is C

A. "You are making progress in your treatment plan." While this response provides positive reinforcement, it doesn't address the client's feelings of frustration or desire to go home, potentially invalidating their emotions.

B. "You should call your partner to discuss this." Suggesting that the client call their partner shifts the focus away from their feelings and may not provide the immediate emotional support they need.

C. "It must be very frustrating for you to be here." This response acknowledges the client's feelings and validates their frustration. It opens the door for further discussion about their emotions, helping the client feel heard and understood.

D. "It would be best to discuss your feelings with your provider." This response may dismiss the client's current feelings by directing them away from the nurse, who is present and capable of providing support. It is important to validate the client's feelings first.

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Correct Answer is D

Explanation

A) Palpable fontanels:By the age of 2, the anterior fontanel (soft spot on the top of the head) should have closed. Palpable fontanels are not expected in a 2-year-old toddler and could indicate a developmental issue.

B) Head circumference exceeds chest circumference:In a 2-year-old, the head circumference typically equals or is slightly less than the chest circumference. This finding is more common in infants rather than toddlers.

C) Natural loss of deciduous teeth:The natural loss of deciduous (baby) teeth usually begins around the age of 6 years. It is not expected in a 2-year-old toddler.

D) Nontender, protruding abdomen:A nontender, protruding abdomen is a normal finding in toddlers due to their developing musculature and posture. This is a common and expected characteristic in children of this age group.

A. Metallic taste in mouth B. Increased urinary frequency C. Excessive sweating D. Dry cough

Correct Answer is C

Explanation

A. Metallic taste in mouth: This is not a commonly reported adverse effect of sertraline. While some medications may cause changes in taste, it is not characteristic of SSRIs like sertraline.

B. Increased urinary frequency: This is not a typical adverse effect associated with sertraline. While changes in urinary patterns can occur with some medications, it is not specifically noted for sertraline.

C. Excessive sweating: This is a recognized adverse effect of sertraline and other SSRIs. Patients may experience increased sweating, which can be uncomfortable and distressing.

D. Dry cough: This is not a common side effect of sertraline. While some medications may lead to respiratory side effects, it is not typical for SSRIs like sertraline to cause a dry cough.

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A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

Correct Answer is C

Explanation

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