The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

It’s important to be out of your room and talking to others.

Watching TV is a passive activity and we want you to be active.

Sometimes clients feel like the TV is sending them messages.

You can watch TV as much as you want outside of your room.

Answer and Explanation

The Correct Answer is A

Choice A reason: Depression involves social withdrawal, driven by low serotonin or dopamine. Encouraging the client to leave the room and engage socially stimulates oxytocin release and cognitive behavioral benefits, counteracting isolation. This therapeutic approach enhances mood and aligns with depression management goals, making it the most effective response.

Choice B reason: Calling TV a passive activity is partially true but less therapeutic, as it doesn’t directly promote social engagement. Depression treatment prioritizes interpersonal interaction to boost neurotransmitters like serotonin. This response misses the opportunity to encourage social therapy, critical for alleviating depressive symptoms in a mental health setting.

Choice C reason: Suggesting TV sends messages is inappropriate without psychotic symptoms, not indicated in this client’s depression. Depression involves low mood, not delusions. This could confuse or stigmatize, failing to promote social engagement, which is essential for improving mood via neurochemical and behavioral pathways in depression management.

Choice D reason: Allowing unlimited TV outside the room does not address depression’s social isolation. Excessive TV may reinforce withdrawal, reducing therapeutic group activities that enhance serotonin. This lacks focus on active engagement, critical for recovery, making it less effective than encouraging social interaction to improve mental health outcomes.

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Correct Answer is B

Explanation

Choice A reason: Blood pressure of 142/88 mm Hg indicates mild hypertension but does not directly affect pulse oximetry, which measures arterial oxygen saturation via hemoglobin light absorption. Hypertension does not typically cause hypoxemia (91% SpO₂). Edema is more likely, as it disrupts sensor accuracy, leading to false low readings.

Choice B reason: 2+ edema in fingers and hands impairs pulse oximeter accuracy, as fluid in tissues scatters light, reducing the sensor’s ability to detect arterial hemoglobin saturation. This causes falsely low SpO₂ readings (91%), common in edema from heart failure, making it the primary contributor to the inaccurate measurement.

Choice C reason: A radial pulse volume of 3+ indicates strong arterial flow, supporting accurate pulse oximetry by ensuring perfusion. This does not explain a low SpO₂ of 91%, as strong pulses enhance sensor reliability. Edema’s interference with light transmission is more likely to cause the reduced reading.

Choice D reason: Capillary refill of 2 seconds is normal, indicating adequate perfusion. This does not contribute to a low SpO₂ (91%), as pulse oximetry measures arterial flow, not capillary dynamics. Edema disrupts light transmission, causing inaccurate readings, making it the most likely cause of the observed saturation.

A. Encourage the application of topical corticosteroids to eczema. B. Explain the use of chemical debridement to reduce blistering. C. Remind the client to restrict the use of heat to 15 to 20 minutes. D. Provide a sling so the left arm can be extended and elevated.

Correct Answer is A

Explanation

Choice A reason: Topical corticosteroids reduce eczema’s inflammation by inhibiting cytokines, alleviating antecubital vesicles. Heat lamps dry skin, worsening irritation and cracking. Encouraging steroids addresses the inflammatory pathophysiology, promoting healing, making this the most effective response for managing eczema and correcting harmful self-treatment.

Choice B reason: Chemical debridement is for necrotic tissue, not eczema’s inflammatory vesicles. Heat lamps exacerbate dryness, but debridement does not address immune-mediated inflammation. Corticosteroids target the cytokine-driven process, making debridement inappropriate for eczema’s pathophysiology, which requires anti-inflammatory treatment.

Choice C reason: Restricting heat to 15–20 minutes does not mitigate harm, as heat dries eczema lesions, disrupting the skin barrier and increasing infection risk. Corticosteroids reduce inflammation, addressing vesicles. Heat worsens epidermal damage, making this response ineffective compared to targeting the inflammatory cause.

Choice D reason: A sling for arm elevation is irrelevant for localized eczema, an inflammatory dermatitis, not edema requiring elevation. Heat lamps aggravate dryness, and corticosteroids treat inflammation, addressing immune-mediated pathology more effectively than positional changes, which do not impact eczema’s skin symptoms.

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The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

Correct Answer is A

Explanation

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

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The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

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