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 B

Explanation

Answer: B. Compare the result with the baseline reading

Rationale:

A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.

B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.

C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.

D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.

A. Administer the medication when the toddler has an acute asthma attack. B. Provide an additional dose of the medication prior to physical activity. C. Mix the medication in juice prior to administration. D. Administer the medication to the toddler each evening.

Correct Answer is D

Explanation

Montelukast is a medication commonly prescribed for the management of asthma symptoms, including the prevention of asthma attacks. The recommended dosing regimen for montelukast is typically once daily, usually in the evening. This helps to provide continuous control of asthma symptoms and reduce the risk of asthma exacerbations.

Administer the medication when the toddler has an acute asthma attack: Montelukast is not intended for immediate relief during an acute asthma attack. It is a long-term control medication aimed at preventing asthma symptoms and reducing the frequency and severity of attacks. For acute asthma attacks, a short-acting bronchodilator such as albuterol is typically used.

Provide an additional dose of the medication prior to physical activity: Montelukast is not specifically indicated as a pre-exercise medication for asthma. However, in some cases, healthcare providers may prescribe it if exercise-induced bronchoconstriction is a significant concern. It is important to follow the specific instructions provided by the healthcare provider regarding medication use before physical activity.

Mix the medication in juice prior to administration: Montelukast tablets or chewable tablets should not be crushed or mixed in juice unless specifically instructed by the healthcare provider. They should be administered whole and taken with water. If the child has difficulty swallowing tablets, alternative formulations like oral granules or chewable tablets may be available.

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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 has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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