A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

Recommend that the client talk with a social worker today.

Offer the client a safe place to relax before the Interview.

Assure client of an interview with the healthcare provider today.

Ask the client to describe the stalker and If It is frequent.

Answer and Explanation

The Correct Answer is B

Choice A Rationale: While talking to a social worker could be beneficial, it may not address the client's immediate need for safety and comfort. Social work intervention is important, but the priority is to ensure the client feels secure in the current environment.
Choice B Rationale: Offering a safe place to relax is crucial as it addresses the client's immediate need for safety and security. Feeling safe can help reduce anxiety and allows the client to compose themselves before discussing their concerns in detail.
Choice C Rationale: Assuring an interview with the healthcare provider is important, but it does not prioritize the client's immediate emotional and psychological needs. The assurance of care is part of the overall treatment plan but is secondary to providing a safe environment.
Choice D Rationale: Asking the client to describe the stalker is part of the assessment process, but it is not the most important initial action. The client's immediate emotional state must be stabilized before any detailed information gathering can be effective.

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Correct Answer is D

Explanation

Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.

Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.

Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.

Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statementsuggests progress in the client's willingness to engage in personal hygiene activities.

A. Remain calm and use a matter-of-fact approach. B. B Assist the client in developing alternative coping skills. C. Administer an as needed (PRN) sedative to help relieve anxiety. D. Ask the client why she is so anxious.

Correct Answer is A

Explanation

Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.

Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.

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A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Correct Answer is A

Explanation

A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?

A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?