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 A

Explanation

The correct answer is a. Call EMS if a seizure lasts 5 minutes or more.

Explanation:

When providing home care instructions for a child with a seizure disorder, it is important to educate the parents about appropriate actions during a seizure. Calling emergency medical services (EMS) if a seizure lasts 5 minutes or more is crucial because it may indicate a condition called status epilepticus, which is a prolonged seizure or a series of seizures without full recovery of consciousness between them. Status epilepticus is a medical emergency that requires immediate medical intervention.

Option b, restraining the child at the onset of a seizure, is not recommended. Restraint can potentially cause harm to the child and increase the risk of injury. It is advised to create a safe environment by removing any nearby objects that could cause injury and placing a pillow or cushion under the child's head to prevent head injury.

Option c, oﬀering the child a bubble bath every evening, is not specifically related to seizure management. Bathing routines can be continued as long as they are safe and supervised. However, it is important to ensure the child's safety during bathing, such as providing adequate supervision to prevent drowning or injury.

Option d, placing the child in a prone position during a seizure, is not recommended. Placing the child in a prone position (face down) during a seizure can obstruct the airway and increase the risk of respiratory complications. The child should be placed on their side, in a recovery position, to facilitate drainage of saliva or other ﬂuids and prevent choking.

Overall, the most important instruction for the parents is to recognize the signs of prolonged seizure activity and to seek immediate medical assistance by calling EMS if a seizure lasts 5 minutes or more.

A. Consume more prepared frozen dinners to minimize cooking with salt. B. Add salt when preparing a meal instead of at the table. C. Use imitation crab and lobster products for salads at home. D. Replace bottled salad dressing with homemade vinegar and oil dressing.

Correct Answer is D

Explanation

A client with heart failure should limit their sodium intake. Bottled salad dressings can be high in sodium, so replacing them with homemade vinegar and oil dressing can help reduce sodium intake.

The other options are not recommended for a client with heart failure who needs to limit their sodium intake.

a) Prepared frozen dinners are often high in sodium.

b) Adding salt when preparing a meal would increase sodium intake.

c) Imitation crab and lobster products (option can also be high in sodium.

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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 is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has heart failure and reports difficulty with limiting sodium in their diet. Which of the following recommendations should the nurse provide?

Correct Answer is D

Explanation

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

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The nurse is checking the home environment of a client for safety hazards. Which of the following items require intervention by the nurse?

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