The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

A family member of a client with dementia who has been missing for five hours.

A client with schizophrenia who wants to stop taking the medications.

The parent of a child who was involved in a physical fight at school today.

A client diagnosed with depression who is experiencing sexual dysfunction.

Answer and Explanation

The Correct Answer is A

Choice A reason: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.

Choice B reason: While medication adherence is important for a client with schizophrenia, it does not present an immediate life-threatening situation. The nurse can return this call after addressing more urgent safety concerns.

Choice C reason: Physical altercations at school are serious, but if the child is safe and not in immediate danger, this call can be returned following more urgent issues.

Choice D reason: Sexual dysfunction can significantly affect quality of life, but it is not an immediate safety concern. This call should be returned after more urgent calls have been addressed.

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Correct Answer is C

Explanation

Choice A reason: Applying a water-soluble lubricant to the catheter is not recommended during tracheostomy suctioning as it may introduce contaminants.

Choice B reason: Instilling sodium chloride before suctioning is not a standard practice and can lead to complications such as edema.

Choice C reason: Wearing protective goggles is important to protect the nurse from potential splashes of bodily fluids during the suctioning process.

Choice D reason: Instructing the client to cough as the suction tip is removed is not recommended as it can cause discomfort and potential harm to the tracheal lining.

A. "Is there any particular reason why you think this is your fault?" B. "You didn't do anything wrong." C. "With surgery, your baby should have a full recovery." D. "This must be a very difficult time for you." E. "This must be a very difficult time for you."

Correct Answer is D

Explanation

Choice A reason: Asking if there is a particular reason why the parent thinks it's their fault may inadvertently validate feelings of self-blame, which is not helpful in this sensitive situation.

Choice B reason: While reassuring the parent they did nothing wrong is true, it may not address the emotional support the parent needs at this moment.

Choice C reason: Promising a full recovery with surgery may be misleading and give false hope, as outcomes can vary and myelomeningocele often results in some degree of impairment.

Choice D reason: Acknowledging the parent's feelings and the difficulty of the situation provides emotional support and validation without assigning blame or making promises about the outcome.

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The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is C

Explanation

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Correct Answer is D

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?

The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

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A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

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