A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed wearing clean clothes, and styled hair. Which of the following responses by the nurse is therapeutic?
"Why are you all dressed up today?”
“I see you have done some grooming today"
“Everyone feels better after showering”
"You must be getting better. You look great”
The Correct Answer is B
This response acknowledges the client's effort and self-care without making assumptions or imposing judgment. It is an open and non-intrusive statement that shows the nurse is paying attention to the client's appearance and recognizing their positive action of self-grooming. It allows the client to share their feelings or thoughts if they choose to without feeling pressured or judged. This response demonstrates empathy and understanding, creating a supportive and non-threatening environment for the client to express themselves if they wish to do so.
Incorrect:
A- "Why are you all dressed up today?" This question may put the client on the spot and make them feel self-conscious or defensive. It assumes that there must be a specific reason for the client's appearance, which may not be the case. It can also imply that the client's usual appearance is different or not as desirable.
C- "Everyone feels better after showering." While it is true that personal hygiene can have a positive impact on one's mood, this statement may come across as dismissive or oversimplifying the client's experience. It may invalidate any underlying emotions or struggles the client is facing with their depression. It is important to acknowledge and address the client's feelings rather than making broad generalizations.
D- "You must be getting better. You look great." This statement assumes that physical appearance is directly correlated with the client's mental health and suggests that improvement in appearance equates to improvement in mental well-being. However, a person's outward appearance may not accurately reflect their internal struggles or progress in managing depression. Additionally, it can create pressure for the client to maintain a certain appearance to be perceived as "better."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.The client runs 4 miles outdoors every afternoon. This is correct. Intense physical activity, especially in hot weather, can lead to dehydration and sodium loss through sweat, both of which can increase the risk of lithium toxicity.
B.The client drinks 2 liters of liquids daily. Adequate fluid intake helps maintain a stable lithium level and is generally recommended to reduce the risk of toxicity.
C. The client eats 2 to 3 gm of sodium-containing foods daily. A consistent intake of sodium helps maintain stable lithium levels. Significant changes in sodium intake, rather than a stable intake, would be more concerning.D. The client eats foods high in tyramine. Tyramine-rich foods are a concern for clients taking MAO inhibitors, not lithium. Therefore, this is not relevant to lithium toxicity.
Correct Answer is D
Explanation
Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.
A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.
B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.
C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.
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