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
Remaining attentive but silent is an appropriate response by the nurse.
This allows the client to express their feelings and concerns without interruption or judgment.
It also shows the client that the nurse is actively listening and interested in what they have to say.
Choice A is not an appropriate response because placing a client on a 72-hour hold should only be done if the client is a danger to themselves or others.
Choice C is not an appropriate response because leaving the room immediately would be unprofessional and could make the client feel abandoned.
Choice D is not an appropriate response because telling the client that everything will be fine may not be true and could give false hope.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Reduced muscle strength, sensory losses like vision and hearing, and slowing of reflexes are all expected physiological changes of the older adult that can put them at risk of falls.
Reduced muscle strength can make it more difficult for older adults to maintain balance and stability.
Sensory losses like vision and hearing can affect an older adult’s ability to perceive their environment and navigate safely.
Slowing of reflexes can make it more difficult for older adults to react quickly to changes in their environment and prevent falls.
Choice D is not an answer because dementia is not a physiological change but rather a cognitive condition that can increase the risk of falls.
Choice E is not an answer because the inability to adapt is not a specific physiological change but rather a general characteristic that can increase the risk of falls.
Correct Answer is ["A","B","E"]
Explanation
CHOICE A. It is important to identify yourself when interacting with a client with a visual impairment so that they know who they are speaking with.
CHOICE B. Ensuring adequate lighting can help the client to see better and make use of any remaining vision they may have [B].
CHOICE E. Providing discharge instructions in large print can make it easier for the client to read and understand the information
CHOICE C. Speaking louder is not necessary for clients with visual impairments unless they also have a hearing impairment
CHOICE D. Avoiding talking to other people in the room is not necessary and may make the client feel excluded from the conversation
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