A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

"You should try to see your partner's point of view before your own.”

"Relationship difficulties are stressful and require effort to resolve.”

"We could develop a plan for how to talk about this with your partner.”

"Tell me more about the concerns that you have regarding your marriage.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.

Choice B rationale:

Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.

Choice C rationale:

Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.

Choice D rationale:

Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.

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Correct Answer is D

Explanation

The correct answer is choice D: "Remain with the client in his room for a while."

Choice D rationale:

This choice is the correct answer because when a client is experiencing panic-level anxiety, their immediate need is for support and reassurance. Staying with the client helps establish a sense of safety and demonstrates the nurse's presence, which can help reduce anxiety. Providing a calming and supportive presence is a therapeutic nursing intervention in this situation.

Choice A rationale:

Medicating the client with a sedative might be appropriate in some cases of severe anxiety, but it should not be the first action taken. Non-pharmacological interventions, such as offering emotional support, should be prioritized before resorting to medication.

Choice B rationale:

Joining a therapy group might be beneficial for the client in the future, but during the acute phase of panic-level anxiety, the client might not be in a state to actively participate and engage in group therapy. Immediate individual attention is necessary.

Choice C rationale:

While suggesting that the client rest in bed could be helpful for relaxation, it might not be sufficient to address the intensity of panic-level anxiety. The client might not be able to rest or calm down without more direct support from the nurse.

A. "I pray when I begin to breathe fast.” B. "I journal when I find it difficult to talk.” C. "I fix myself a pot of coffee when I get anxious.” D. "I exercise when my neck is tense.”

Correct Answer is C

Explanation

Choice A rationale:

Praying and using relaxation techniques when experiencing rapid breathing are effective stress management strategies. These techniques help manage the body's stress response and promote relaxation.

Choice B rationale:

Journaling is a constructive way to manage stress, especially when verbal expression is difficult. It allows individuals to reflect on their thoughts and emotions, leading to a sense of relief.

Choice C rationale:

"Fixing a pot of coffee" when anxious is the least effective technique mentioned. Consuming large amounts of caffeine can exacerbate anxiety symptoms by increasing heart rate and contributing to a sense of restlessness and nervousness.

Choice D rationale:

Engaging in physical exercise when experiencing tension in the neck is a productive strategy. Exercise promotes the release of endorphins, which are natural mood lifters and stress reducers.

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A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room, which of the following nursing actions is most therapeutic at this time?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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