A client states, *I don't know what to do. My life is a mess." What is an appropriate response by the nurse?
Place the client on a 72-hour hold immediately
Remain attentive, but silent
Leave the room immediately
Tell the client that everything will be fine
The Correct Answer is B
An appropriate response by the nurse to a client who states, "I don't know what to do. My life is a mess." would be to remain attentive and engage with the client in a therapeutic way. This type of statement by the client may indicate feelings of hopelessness, despair, or even suicidal ideation, so it's important for the nurse to respond in a supportive and empathetic manner.
Placing the client on a 72-hour hold immediately would not be an appropriate response unless the client presents an imminent danger to themselves or others. Similarly, leaving the room immediately or telling the client that everything will be fine would not address the client's concerns or provide appropriate support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The statement "Take naps when drowsy" is not appropriate client education for a client experiencing insomnia. Insomnia is a sleep disorder characterized by difficulty falling or staying asleep, or waking up too early in the morning. Napping during the day can make it harder for someone with insomnia to fall asleep at night. Therefore, advising a client with insomnia to take naps when drowsy can exacerbate their sleep problem.
Regular exercise can improve the quality and duration of sleep.
Limiting fluids before bedtime can reduce the need to wake up during the night to use the bathroom.
Alcohol can disrupt sleep as well, so limiting or avoiding alcohol before bedtime can help improve sleep quality.
Correct Answer is C
Explanation
If a client begins to fall while the nurse is assisting with ambulation, the priority nursing intervention is to guide the client safely to the floor. The nurse should assist the client to fall as safely as possible to prevent further injury. The nurse should also stay with the client, assess their condition, and call for assistance if necessary.
Initiating a code or calling the client's doctor may not be necessary at this time, as the client's condition may not require such drastic measures. Similarly, calling the charge nurse may be helpful, but it is not the priority intervention in this scenario.
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