A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?

"You may think you are fat, but you look thin to me."

"There are consequences for not eating."

"Explain how you feel when it is time to eat."

"You must eat or you will become very sick."

Answer and Explanation

The Correct Answer is C

Choice A rationale: "You may think you are fat, but you look thin to me" is dismissive and may invalidate the client's feelings. It is essential to explore the client's emotions rather than providing a judgmental response.

Choice B rationale: "There are consequences for not eating" is confrontational and may increase the client's anxiety. A more therapeutic approach involves exploring the client's feelings and concerns about eating.

Choice C rationale: "Explain how you feel when it is time to eat" is an open-ended and non-judgmental response. It encourages the client to express her emotions, providing valuable information for further assessment and care planning.

Choice D rationale: "You must eat or you will become very sick" is directive and may increase resistance. It is essential to explore the client's feelings and collaborate on a plan rather than issuing directives.

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Correct Answer is A

Explanation

Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.

Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.

A. Refer the client to the cardiology clinic. B. Obtain the client's blood pressure. C. Determine if alprazolam was taken recently. D. Assess the client for substance abuse.

Correct Answer is B

Explanation

Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.

Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.

Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.

Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.

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A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Correct Answer is A

Explanation

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?

Correct Answer is B

Explanation

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After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?