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 D
Explanation
Collaborate with the client and provider to develop a client-centered plan of care.
It is important for the nurse to respect the client’s cultural and religious beliefs while also ensuring that his medical needs are met.
By collaborating with the client and his healthcare provider, the nurse can help develop a plan of care that takes into account the client’s desire to fast during Ramadan while also managing his diabetes.
Choice A) Educating the client that fasting is not an option is not respectful of the client’s beliefs and may not be effective in promoting adherence to treatment.
Choice B) Telling the client not to take his insulin the night before is not appropriate as it may result in uncontrolled blood sugar levels.
Choice C) Informing the client that he will need to change his lifestyle completely is not a client-centered approach and may not be effective in promoting adherence to treatment.
Correct Answer is D
Explanation
Encouraging bed rest would be an inappropriate nursing intervention to promote mobility for a client with decreased mobility.
Bed rest can lead to further complications of immobility1.
Choice A is not an answer because teaching the client to do active range of motion (AROM) exercises every 2 hours can help maintain joint mobility and muscle strength2.
Choice B is not an answer because evaluating the client’s need for ambulatory aids can help them move safely and independently1.
Choice C is not an answer because keeping skin clean and dry is important for preventing skin breakdown, which can be a complication of immobility1.
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