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
This scenario is an example of cultural imposition. The nurse is imposing her own beliefs and values regarding infant safety onto the African mother, without considering the cultural context in which the mother is from.
To provide culturally competent care, it is important to respect and understand different cultural practices and beliefs, and work collaboratively with clients to develop safe and effective care plans that are culturally appropriate.
Correct Answer is B
Explanation
The temperature and respiratory rate in this set are within normal limits. However, the low pulse rate and the high blood pressure are significant findings that require further evaluation. A pulse rate of 54 bpm may indicate a slow heart rate, which can lead to decreased cardiac output and other related symptoms.
A blood pressure of 196/114 mmHg is significantly higher than normal and may indicate hypertension, which can lead to serious health complications if left untreated.
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