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

Hyponatremia refers to a lower-than-normal level of sodium in the blood. Sodium is an essential electrolyte involved in various bodily functions, including maintaining fluid balance and transmitting nerve impulses. When sodium levels are low, it can lead to fluid imbalances, affecting the function of muscles and nerves. Muscle cramps are a common manifestation of hyponatremia and occur due to alterations in muscle excitability and contractility.

Constipation: Constipation is not typically associated with hyponatremia. It can occur due to various reasons, such as dietary factors, lack of physical activity, or other medical conditions, but it is not a direct consequence of low sodium levels.

Hypertension: Hyponatremia is not usually associated with hypertension (high blood pressure). Hypertension can be caused by several factors, including genetics, lifestyle, and certain medical conditions, but it is not directly related to low sodium levels.

Blurred vision: While blurred vision can occur in some medical conditions, such as diabetes or certain eye disorders, it is not a typical finding in hyponatremia. Visual disturbances are not a direct consequence of low sodium levels.

A. Instruct the client to bear down during rectal tube insertion. B. Administer a second enema if results are not clear. C. Assist the client to a right Sims' position D. Insert the rectal tube in the direction of the client's umbilicus.

Correct Answer is C

Explanation

When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.

The other options are not correct because:

a) The client should not bear down during rectal tube insertion.

b) Administering a second enema if results are not clear is not mentioned as a safety precaution.

d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.

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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 collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

Correct Answer is C

Explanation

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