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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Tenderness: Tenderness during percussion could indicate an underlying issue, such as inflammation or infection, and is not a normal finding.

B. Pain: Pain during percussion may suggest problems like organ inflammation or distension and is not considered normal.

C. Musical and drumlike: This finding is normal and is often indicative of the presence of air or gas in the intestines, which is a common finding in older adults, especially those with less efficient digestion.

D. Absent sounds: Absent sounds could indicate bowel obstruction or other serious issues and are not a normal finding. Normal percussive sounds should be heard.

A. pH 7.40 B. Blood pressure 112/77mm Hg C. PaCO2 42 mm Hg D. Surgical dressing dry and intact E. Temperature 98.1° F (37.4° C) F. Capillary refill 2 seconds G. Pain 0 on a scale of 0 to 10

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"D"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Rationale:

pH 7.40: A pH of 7.40 indicates that the client's acid-base balance is normal. This supports ventilation as the client’s respiratory system is effectively managing gas exchange.
Blood pressure 112/77 mm Hg: This stable blood pressure is a sign that the client is adequately perfused, indicating management of hypovolemia. The blood pressure is now within a normal range, suggesting effective fluid resuscitation.
PaCO2 42 mm Hg: The PaCO2 of 42 mm Hg is within normal limits, showing that the client's ventilation is adequate and confirming support of ventilation.
Surgical dressing dry and intact: The intact dressing is important for preventing infection, as it ensures that there is no leakage or exposure to bacteria at the surgical site.
Temperature 98.1° F (36.7° C): A temperature of 98.1° F (36.7° C is a normal and suggests successful rewarming or maintenance of normothermia, which contributes to Prevent infection as hypothermia can impair immune function and increase infection risk.
Capillary refill 2 seconds: Capillary refill of 2 seconds is within normal limits and indicates good circulation and tissue perfusion, which is part of managing hypovolemia.
Pain 0 on a scale of 0 to 10: The client’s report of no pain (pain score of 0) indicates that the goal of controlling pain and anxiety is being met, ensuring that the client is comfortable and stable.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"D"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

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