A nurse is caring for a client who was recently admited to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?

I think you should just ignore the others

You feel upset by the responses of others

Let's keep the focus of our discussion on your needs

Everything will get beter once you get to know everyone.

Answer and Explanation

The Correct Answer is B

b. "You feel upset by the responses of others."

The appropriate response by the nurse is to acknowledge and validate the client's feelings. Option b, "You feel upset by the responses of others," demonstrates empathy and reﬂects back the client's feelings, indicating that the nurse understands and acknowledges the client's distress.

Explanation for the other options:

a. "I think you should just ignore the others." This response dismisses the client's concerns and does not address the underlying issue of the client feeling hurt by the interactions with others. It is important for the nurse to address the client's feelings and provide support.

c. "Let's keep the focus of our discussion on your needs." While it is important to address the client's needs, it is also necessary to address the client's concerns and feelings related to the interactions with other clients. Ignoring or dismissing the client's concerns can further isolate the client and hinder their progress in the therapeutic environment.

d. "Everything will get beter once you get to know everyone." This response minimizes the client's feelings and does not provide immediate support or address the client's concerns. It is essential for the nurse to validate the client's emotions and explore strategies to address the issue of others making fun of the client.

In summary, the nurse should choose a response that acknowledges the client's feelings and demonstrates empathy. Validating the client's experience can help establish trust and provide a foundation for further therapeutic interventions.

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Correct Answer is C

Explanation

c. Dispose of the used needle immediately in a sharps container.

The nurse should dispose of the used needle immediately in a sharps container to reduce the risk of a needlestick injury. Sharps containers are specifically designed for the safe disposal of needles and other sharp objects. By placing the used needle directly into a sharps container, the nurse eliminates the need for handling or manipulating the needle further, reducing the risk of accidental needlestick injuries.

Explanation for the other options:

a. Place a cap holder securely on the used needle before disposal: Cap holders are not recommended for securing used needles before disposal. They may not provide adequate protection against needlestick injuries and can potentially increase the risk of accidental needlesticks when atempting to secure the cap holder.

b. Recap the needle for disposal later: Recapping the needle increases the risk of a needlestick injury. It is generally not recommended to recap needles after use, as it poses a greater risk of accidental puncture.

d. Detach the used needle and dispose of it promptly: Detaching the needle from the syringe before disposal is not recommended, as it increases the risk of a needlestick injury. It is safer to dispose of the needle and syringe as a unit in a sharps container to minimize the risk of accidental puncture.

A. The client's most recent blood pressure reading was 110/60 mm Hg. B. The client's morning laboratory results included a potassium level of 4.9 mg/dL. C. The client has +2 pitting edema in the lower extremities. D. The client's partner assisted them with their meal tray.

Correct Answer is D

Explanation

The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.

A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.

The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.

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A nurse is caring for a client who was recently admited to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse administered an IM injection to a client. Which of the following actions should the nurse take to reduce the risk of a needlestick injury?

Correct Answer is C

Explanation

A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?

Correct Answer is D

Explanation

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