A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Tell me what is concerning you."

"Your husband is making really good progress."

"Did your husband say something to upset you?"

"Crying helps us let things out and we feel better."

Answer and Explanation

The Correct Answer is A

A. "Tell me what is concerning you."

This response is the most therapeutic option. It invites the spouse to share their concerns and feelings, showing empathy and active listening. It opens the door for effective communication and understanding the spouse's perspective.

B. "Your husband is making really good progress."

While this response provides information about the husband's progress, it doesn't directly address the spouse's concerns or feelings. The spouse's emotional state needs to be acknowledged and explored before discussing the husband's progress.

C. "Did your husband say something to upset you?"

This response makes an assumption that the husband said something to upset the spouse. It might come across as accusatory or dismissive of the spouse's feelings. It's important to give the spouse the opportunity to express their emotions in their own words.

D. "Crying helps us let things out and we feel better."

This response offers a general statement about crying, but it doesn't directly address the spouse's concerns or invite further conversation. While it's true that crying can be cathartic, the focus here should be on understanding the spouse's specific worries.

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Correct Answer is A

Explanation

A.Lithium is excreted through the kidneys, and dehydration and sodium depletion increase the risk of lithium toxicity. A client who runs 4 miles outdoors every afternoon is at risk of excessive sweating and fluid loss, which can lead to dehydration and sodium depletion. This reduces lithium excretion, leading to toxic levels in the blood.

B. Anormal sodium intake helps maintain lithium balance. A low sodium intake increases lithium retention, but 2-3 grams/day is within the normal recommended range.

C. Adequate hydration helps prevent lithium toxicity. Clients on lithium should drink 2–3 liters of fluid daily to promote kidney function and lithium excretion.
D. Tyramine-rich foods (e.g., aged cheese, cured meats) are a concern for clients on monoamine oxidase inhibitors (MAOIs), not lithium. Tyramine does not affect lithium levels.

A. "I may have a dry mouth while taking this medication." B. "This medication will help me stop smoking." C. I should expect flu-like symptoms while taking this medication." D. This medication may cause me to urinate frequently."

Correct Answer is A

Explanation

A. "I may have a dry mouth while taking this medication.":

Explanation: Correct Answer. Dry mouth is a common side effect of chlorpromazine, which is a typical antipsychotic medication. This statement indicates that the client understands the potential side effects of the medication.

B. "This medication will help me stop smoking.":

Explanation: This statement is incorrect. Chlorpromazine is not used as a medication to aid in smoking cessation. It is primarily used to treat conditions such as schizophrenia and other psychotic disorders.

C. "I should expect flu-like symptoms while taking this medication.":

Explanation: This statement is incorrect. Flu-like symptoms are not a common side effect of chlorpromazine. Side effects more commonly associated with chlorpromazine include drowsiness, dizziness, and movement-related issues.

D. "This medication may cause me to urinate frequently.":

Explanation: This statement is incorrect. While chlorpromazine can cause various side effects, increased frequency of urination is not one of the typical side effects associated with this medication.

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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

Correct Answer is A

Explanation

A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

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