A client is agitated and pacing in the hall near the nurses' station and swearing loudly. What response is the best for the registered nurse to provide?
Select one:
Others are being distracted; Please, quiet down and go to your room.
You seem pretty upset. Tell me about it
Please go to your room to get control of yourself.
What’s going on? Be quiet.
The Correct Answer is B
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Refeeding syndrome is a potentially life-threatening complication that can occur when a person with anorexia nervosa or other forms of malnutrition begins to eat again after a period of starvation. It is characterized by electrolyte imbalances and fluid shifts that can lead to cardiovascular dysfunction, including heart failure and arrhythmias. Therefore, when caring for a patient with anorexia nervosa who is being refed, it is important for the nurse to closely monitor the patient’s cardiovascular system for signs of dysfunction.
Option a. Endocrine system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option b. Respiratory system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option c. Musculoskeletal system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Correct Answer is D
Explanation
During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.
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