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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The working phase of the nurse-client relationship entails the implementation of interventions and evaluation of outcomes while modifying the plan of care with need. The nurse supports and educates the client while helping them to cope with their situation. This process requires constant communication, trust, and collaboration between the nurse and the client.

A. Chloride and sodium B. Water and vitamins C. Sodium and water D. Potassium and water

Correct Answer is C

Explanation

Choice A rationale: Both sodium and chloride are important for fluid balance but chloride has no effect on the blood lithium levels.
Choice B rationale: sodium has an effect on the blood lithium levels by competing with lithium for reabsorption in the kidneys but vitamins do not influence the lithium levels in blood.
Choice C rationale: dehydration increases the risk of lithium toxicity since it will result in oliguria hence increasing the risk of lithium toxicity since the drug is primarily excreted in urine. Sodium and lithium compete for reabsorption in the kidneys, so low sodium levels can increase lithium retention and lead to toxicity. Therefore, the client should maintain an adequate intake of sodium and water to prevent dehydration and sodium loss and to keep the lithium level within the therapeutic range.
Choice D rationale: water has an influence on blood lithium levels since adequate intake minimizes the risk of toxicity by increasing the drug’s excretion in urine.
However, potassium does not compete with lithium for reabsorption.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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