A mental health nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?
"Do you think your anxiety is worse than everyone else's?"
"It doesn't appear as though you are feeling anxious."
"Tell me what has been happening lately."
"I think you should see a therapist and a doctor tomorrow.".
The Correct Answer is C
Choice A, "Do you think your anxiety is worse than everyone else's?", is invalidating and minimizes the client's experience. Comparing their anxiety to others is unhelpful and could further distress the client.
Choice B, "It doesn't appear as though you are feeling anxious.", is dismissive and ignores the client's self-report. This dismissive response could damage the therapeutic relationship and discourage the client from sharing openly.
Choice D, "I think you should see a therapist and a doctor tomorrow.", is directive and potentially premature. While suggesting mental health resources can be helpful, it's crucial to first understand the client's situation and preferences before making recommendations. Additionally, suggesting both a therapist and a doctor without further assessment might overwhelm the client.
Choice C, "Tell me what has been happening lately.", is an open-ended and validating that encourages the client to share their experiences and concerns. This shows the nurse is actively listening and creates a safe space for the client to explore their anxiety. By understanding the context and potential triggers, the nurse can then provide more tailored support and guidance.
Further rationale for Choice C:
Open-ended s are key tools in therapeutic communication. They promote client engagement, facilitate exploration of thoughts and feelings, and gather valuable information needed for assessment and planning.
Validating the client's experience is crucial in building trust and rapport. Recognizing and acknowledging their anxiety shows the nurse cares and is taking their concerns seriously.
This initial allows the client to guide the conversation, focusing on aspects they feel most comfortable sharing. This empowers the client and promotes autonomy.
Following the client's lead in the conversation also helps the nurse gather specific details about the nature and severity of the anxiety, informing subsequent assessment and intervention strategies.
In conclusion, Choice C, "Tell me what has been happening lately.", is the most appropriate response for a mental health nurse to use when assessing a client who reports an increase in anxiety. It demonstrates active listening, validates the client's experience, encourages engagement, and provides a foundation for further assessment and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
“Behavioral contract.” While a behavioral contract can be a useful tool in managing certain behaviors, it is not typically the primary intervention used in the discharge planning for a client with borderline personality disorder.
Choice B rationale:
“Dialectical behavior therapy.” This is the correct answer. Dialectical behavior therapy (DBT) is a type of cognitive-behavioral therapy that is specifically designed to help people with borderline personality disorder. It focuses on teaching coping skills to combat destructive urges, encourages mindfulness, improves relationships, and helps with emotional regulation.
Choice C rationale:
“Safety plan.” While a safety plan is important for all clients, it is not the primary intervention for a client with borderline personality disorder. A safety plan is more commonly used for clients who are at risk of self-harm or suicide.
Choice D rationale:
“Bibliotherapy.” Bibliotherapy, the use of books as therapy, can be a useful adjunctive treatment for some individuals. However, it is not typically the primary intervention used in the discharge planning for a client with borderline personality disorder.
Correct Answer is C
Explanation
Choice A rationale:
While assigning a client to a private room might seem like a way to protect their privacy and offer a calm environment, it could also create isolation and reduce opportunities for observation by staff. This could increase the risk of a subsequent suicide attempt without timely intervention.
It's essential to balance privacy with safety needs, and a private room might not always be the most appropriate choice for a client who has recently attempted suicide.
Choice B rationale:
Placing metal utensils on the client's meal tray could introduce potential weapons that could be used for self-harm. It's crucial to remove any objects that could be used for suicide attempts, including utensils, sharp objects, belts, cords, or medications.
Providing safe alternatives, such as plastic utensils, is essential to reduce the risk of harm.
Choice C rationale:
Inspecting the client's personal belongings is a critical safety measure to ensure they don't have access to items that could be used for self-harm. This includes checking for sharp objects, medications, ropes, belts, or other potential hazards.
Removing any such items is essential to create a safe environment and reduce the risk of further suicide attempts.
Choice D rationale:
Tucking bedcovers over the client's hands and arms might restrict their movement, but it doesn't address the underlying risk of suicide. It's not an effective method of preventing self-harm, and it could even cause discomfort or agitation to the client.
More direct and comprehensive safety measures, such as close observation and removal of potential hazards, are necessary.
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