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 A

Explanation

The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.

A. "If I wake up at night, I go to another room and read for 20 minutes." B. "I eat my evening meal at least 3 hours before I go to bed." C. "I watch the television in my bedroom to help me sleep." D. "I have stopped taking naps in the afternoon."

Correct Answer is C

Explanation

"I watch the television in my bedroom to help me sleep." This technique requires further teaching as watching TV before sleep is a poor sleep hygiene habit. Clients should be advised to keep TVs, mobile phones, and other electronic devices out of the bedroom, as electronic devices can be a source of stimulation and disrupt a sleep routine. Adequate sleep hygiene techniques include going to bed and waking up at the same time every day, avoiding caffeine, nicotine, and alcohol, and engaging in physical activity early in the day. Reading for a few minutes or engaging in some other relaxing activity can reduce difficulty falling back to sleep.

Option A: "If I wake up at night, I go to another room and read for 20 minutes" - This is a good sleep hygiene habit

Option B: "I eat my evening meal at least 3 hours before I go to bed" - This is a good sleep hygiene habit Option D: "I have stopped taking naps in the afternoon" - This is a good sleep hygiene habit Each of the other options helps with good sleep hygiene but C will not help.

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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 patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?

Correct Answer is A

Explanation

A nurse is discussing insomnia management techniques with a group of clients who have anxiety disorders. Which of the following techniques mentioned by a client requires further teaching?

Correct Answer is C

Explanation

A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which of the following findings should the nurse recognize as a potential indication of abuse?

A nurse is collecting data from a client who is admitted to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

A nurse in an urgent care clinic is caring for a client who is using loud and rapid speech and continuously repeats, "I don't know why my wife left me." Which of the following levels of anxiety is the client experiencing?

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following is an expected finding?