The mental health nurse is leading a group about relaxation and explains the benefits of deep breathing for relaxation. As a female client begins to explain how she uses yoga to relax, another client interrupts and asks, "What's yoga?" Which is the nurse's best response?
"Yoga is not the subject of this group."
"What do you want to know about it?"
"Wait, let her finish talking."
"Do not interrupt in group again."
The Correct Answer is B
A. "Yoga is not the subject of this group": This response dismisses the client's curiosity and could shut down the conversation. Shutting down the discussion abruptly can make clients feel unheard and discourage participation, hindering the therapeutic environment.
B. "What do you want to know about it?": This response validates the client's interest and encourages open discussion. The nurse can provide a brief explanation without derailing the group session.
C. "Wait, let her finish talking": This response may seem dismissive and could discourage engagement. It is important to address the interruption respectfully while also encouraging dialogue.
D. "Do not interrupt in group again": This kind of response can create a hostile environment, shut down communication, and damage the therapeutic relationship between the nurse and the clients, especially in a mental health setting where trust and open expression are vital.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"D"},"D":{"answers":"A"}}
Explanation
Rationale:
- Assessment: This describes the findings relevant to the current situation, such as the elevated digoxin level (2.2 ng/mL), the client’s heart rate (79 beats/minute), and the absence of symptoms such as decreased perfusion, indicating that the client is stable for now.
- Background: Provides necessary patient details, such as age, diagnosis (heart failure), and the fact that the client has been on digoxin for three days, so the nurse provides a brief clinical history relevant to the current issue.
- Recommendation: The nurse suggests rechecking the digoxin level the next day to assess if it has returned to the therapeutic range. Suggests an action to the healthcare provider (recheck digoxin level tomorrow) and indicates that the nurse will monitor the client closely for any changes.
- Situation: The nurse is holding the digoxin due to the elevated level, which exceeds the therapeutic range. This introduces the immediate reason for the call, explaining the context of the patient's condition and recent treatment.
Correct Answer is A
Explanation
A. Palpate the client's suprapubic area for distention: The symptoms suggest possible urinary retention, which could be a result of benign prostatic hyperplasia (BPH) or another obstruction. Palpating the suprapubic area for distention is important to assess for urinary retention and determine if the bladder is full.
B. Obtain a urine specimen for culture and sensitivity: Although a urinary tract infection can cause urinary symptoms, the client's presentation is more likely indicative of a physical obstruction such as BPH. A culture might be needed later if infection is suspected.
C. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important, especially in older adult men, but this is not the most relevant action for the symptoms described. The focus should be on assessing for possible urinary retention or obstruction.
D. Advise the client to maintain a voiding diary for one week: While a voiding diary may provide useful information for monitoring symptoms over time, the immediate priority is to assess for urinary retention and bladder distention.
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