An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

"You are probably right. Soiling the bed is a way of getting attention from the nursing staff."

"Tell me what makes you feel the client is doing this on purpose?"

"Why don't you spend more time with the client if you think that she is trying to get attention?"

"Next time this happens, tell me and I'll talk to the client about his behavior."

Answer and Explanation

The Correct Answer is B

When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.

Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.

Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.

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Correct Answer is D

Explanation

Difficulty maintaining sustained attention is a common manifestation of ADHD, according to the American Psychiatric Association and the CDC. This means that people with ADHD often have trouble focusing on tasks or activities for a long period of time, especially if they are boring or tedious.

The other choices are not manifestations of ADHD, but of other conditions or problems. Here are some reasons why:

Choice A: Difficulty using words in context is not a symptom of ADHD, but of a language disorder or a learning disability that affects communication skills.

Choice B: Difficulty performing self-grooming activities is not a symptom of ADHD, but of a physical disability, a mental health disorder, or a lack of motivation or self-care.

Choice C: Difficulty in acquiring reading skills is not a symptom of ADHD, but of dyslexia, which is a specific learning disability that affects reading and spelling.

A. The client pretends to be a government agent. B. The client reports seeing bugs crawling on the walls. C. The client describes an increase in pain after receiving meperidine. D. The client reports his heart is beating out of his chest.

Correct Answer is D

Explanation

"The client reports his heart is beating out of his chest." as this symptom is consistent with anxiety and the client's prescription is for PRN anxiety. Alprazolam is a medication used to treat anxiety disorders and symptoms of anxiety.

Choice A, "The client pretends to be a government agent," is not a symptom that would be treated with alprazolam.

Choice B, "The client reports seeing bugs crawling on the walls," may indicate the presence of a hallucination or other mental health symptom, but is not related to anxiety and is not an appropriate indication for alprazolam.

Choice C, "The client describes an increase in pain after receiving meperidine," indicates a potential adverse drug effect and is not related to anxiety or an indication for alprazolam.

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An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following manifestations should the nurse expect to find?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following situations should the nurse administer the alprazolam?

Correct Answer is D

Explanation

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