A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Ignore the nonverbal behavior and focus on the client's verbal messages.

Integrate the verbal and nonverbal messages and interpret them as one.

Ask the client's spouse to interpret the discrepancy.

Pay close attention and document the nonverbal messages.

Answer and Explanation

The Correct Answer is D

A.   Ignoring nonverbal behavior may overlook important cues that could provide valuable insight into the client's condition and needs.
B.   Integrating verbal and nonverbal messages is important, but it may not address the discrepancy or the potential significance of the nonverbal cues.
C.   Asking the client's spouse to interpret the discrepancy may not be appropriate or effective, as the spouse may not fully understand the client's nonverbal cues or their significance.
D.   Paying close attention and documenting nonverbal messages allows the nurse to gather comprehensive data and potentially explore the observed discrepancy further in subsequent interactions or assessments.

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Correct Answer is C

Explanation

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

A. The client talks to her father and her best friend when she starts to feel sad. B. The client states she feels numb when thinking about the crash. C. The client states that she avoids driving altogether and takes the bus. D. The client reports sleeping 6 to 7 hours per night. E. The client states she feels less jumpy and more relaxed.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

-The client talks to her father and her best friend when she starts to feel sad. Effective: Seeking support from loved ones and communicating feelings is a positive coping mechanism for dealing with sadness.
-The client states she feels numb when thinking about the crash.
Ineffective: Feeling numb can indicate emotional detachment, which may suggest unresolved trauma and could be indicative of ineffective treatment.
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-The client states that she avoids driving altogether and takes the bus.
Effective: Avoiding triggering situations, such as driving, can be a healthy coping strategy to manage distress associated with traumatic events.
-The client reports sleeping 6 to 7 hours per night.
Effective: Sleeping adequately is essential for mental health and overall well-being. Reporting sufficient sleep suggests improvement.
-The client states she feels less jumpy and more relaxed.
Effective: Feeling less jumpy and more relaxed indicates a reduction in anxiety symptoms, suggesting that treatment has been effective in managing anxiety.

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A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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