The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?

Implement interventions designed to address the client’s needs

Teach the client necessary self-care skills

Facilitate the client’s expression of emotions

Establish a therapeutic nurse-client relationship

Answer and Explanation

The Correct Answer is D

Choice A reason: Implementing interventions addresses specific needs but is not the primary goal of therapeutic communication during admission. Interventions follow after building trust, as depression and anxiety require a strong therapeutic alliance to ensure effective treatment engagement, making this a secondary priority at this stage.

Choice B reason: Teaching self-care skills is important for long-term management but not the initial communication goal. Clients with depression and anxiety need trust and emotional safety first to engage in learning, making skill-building secondary to establishing a therapeutic relationship during the admission assessment.

Choice C reason: Facilitating emotional expression is a key component of therapeutic communication but depends on a trusting relationship. Without a strong nurse-client bond, clients with depression and anxiety may resist sharing emotions, making this goal important but secondary to establishing rapport during the initial assessment.

Choice D reason: Establishing a therapeutic nurse-client relationship is the priority during admission, as it builds trust and safety, critical for clients with depression and anxiety. This foundation enables emotional expression, engagement in interventions, and skill-building, ensuring effective communication and treatment adherence, making it the primary goal in this context.

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Correct Answer is A

Explanation

Choice A reason: In the oliguric phase of AKI, kidney function is severely impaired, reducing potassium excretion. This leads to hyperkalemia, which disrupts cardiac electrical activity, potentially causing life-threatening arrhythmias or cardiac arrest. Elevated potassium levels are a hallmark of this phase due to decreased glomerular filtration rate and impaired tubular secretion.

Choice B reason: Urine output of 2000 mL in 24 hours indicates polyuria, characteristic of the recovery phase of AKI, not the oliguric phase, where output is typically less than 400 mL/day. High urine output suggests restored renal function, which is not expected in the oliguric phase, where kidneys fail to filter adequately.

Choice C reason: Tachycardia may occur in AKI due to fluid overload causing increased cardiac workload or electrolyte imbalances like hyperkalemia affecting heart rhythm. However, it is a secondary symptom and less specific than hyperkalemia, which directly results from impaired renal excretion and poses a more immediate risk to cardiac function.

Choice D reason: Tenting of the skin indicates dehydration, which may precede AKI but is not typical in the oliguric phase, where fluid retention is more common due to reduced urine output. Fluid overload leads to edema, not dehydration, making skin tenting an unlikely finding in this phase of AKI.

A. A documented nursing assessment every hour B. Constant one-on-one supervision during the first hour and then video monitoring C. A face-to-face evaluation by the psychiatrist within one hour of restraint D. Review of the appropriateness of restraints every hour

Correct Answer is C

Explanation

Choice A reason: Hourly nursing assessments are important for monitoring safety in restraints but are not the primary legal requirement. Assessments ensure no physical harm, but psychiatric evaluation within one hour is mandated to confirm restraint necessity, making this option secondary in priority for immediate post-restraint protocol.

Choice B reason: Constant supervision may be used, but transitioning to video monitoring after one hour does not meet strict regulatory standards for restraints. Face-to-face psychiatric evaluation within one hour is required to assess ongoing need and ensure patient rights, making this option less accurate for legal compliance.

Choice C reason: Regulatory standards (e.g., CMS, Joint Commission) mandate a face-to-face evaluation by a psychiatrist within one hour of initiating restraints to assess necessity, safety, and alternatives. This ensures compliance with mental health laws, protects patient rights, and prevents overuse, making it the required action.

Choice D reason: Reviewing restraint appropriateness hourly is part of ongoing care but is not the primary requirement. A psychiatrist’s face-to-face evaluation within one hour takes precedence to ensure legal and ethical use, as it confirms the clinical justification for restraints, making this option secondary.

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The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

Correct Answer is A

Explanation

An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

Correct Answer is C

Explanation

A nurse working on a psychiatric unit receives a telephone call from a client’s employer requesting a copy of the client’s psychological evaluation results. Based on the nurse’s knowledge of breach of confidentiality, which response would be appropriate?

The nurse is receiving the morning report on four clients on a medical-surgical unit. Based on the information provided, which clients are at greatest risk for developing end-stage renal disease (ESRD)? (Select all that apply)

A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client’s diet to maximize the therapeutic effect and minimize the risks of complications. The client’s diet should include which of the following modifications?

The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

Which statement about nonverbal communication is accurate?

The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?