The nurse is talking with the client in an activity room where others are present. The client becomes tearful when talking about his children at home. What is the nurse's best action?
Distract the client by encouraging him to join the group activity
Ask the client to talk more about his children
Take the client into a private area to continue the conversation
Ask the client why he is crying
The Correct Answer is C
Choice A rationale: This is inappropriate since it does not address the client’s feelings about his/her children and may make the client feel that their feelings are not important and have been disregarded.
Choice B rationale: this is inappropriate since the client’s family issues will be exposed if they talk about them in a room full of other patients hence this will potentially increase his distress.
Choice C rationale: taking the client to a private room respects their right to privacy and dignity. Furthermore, it is a form of empathy and would encourage the client to open up with ease to the nurse.
Choice D rationale: asking the client why he is crying sounds judgmental and accusatory hence this may prevent the client from opening up to the nurse concerning his children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The AIMS Scale refers to the Abnormal Involuntary Movement Scale and is used in the assessment of patients for the presence of involuntary movements across body regions. The score ranges from zero which denotes the absence of dyskinesia and four which stands for severe, maximal amplitude and persistence of the abnormal movements during the examination period. It is also used to monitor clients with tardive dyskinesia.
Choice B rationale: the Hamilton scale is a multiple-item questionnaire used in the assessment of clients for depression and provides a guide for patient recovery evaluation.
Choice C rationale: the Braden Scale is used in the assessment of clients for the risk of pressure ulcers.
Choice D rationale: the Morse Scale is a Fall Risk Assessment tool used in assessing the probability of a client sustaining a fall.
Correct Answer is C
Explanation
Choice A rationale: fats are directly related to lithium therapy and does not require any special monitoring during the drug’s intake.
Choice B rationale: proteins do not affect the blood levels of lithium hence they do not require any special monitoring during the drug’s intake.
Choice C rationale: Lithium is a salt that can affect the fluid and electrolyte balance in the body and competes with sodium for their reabsorption in the kidneys.
Therefore, if the client consumes too much or too little sodium, it can alter the level of lithium in the blood and cause toxicity or ineffectiveness hence the need for close monitoring.
Choice D rationale: potassium does not affect the blood levels of lithium hence no special monitoring during intake is required.
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