A nurse is caring for a client who has a substance use disorder. The client states, "The state took my child away after my overdose. I don't want to go on living without them." Which of the following therapeutic responses should the nurse make?

"If you attend counseling, you will get your child back."

"We can ask the physician to prescribe a sedative."

"Have you thought about harming yourself?"

"Can a family member try to obtain temporary custody of your child?"

Answer and Explanation

The Correct Answer is C

Choice A reason: This response is not therapeutic as it provides false assurance and may not be accurate. The return of the child depends on many factors beyond just attending counseling.

Choice B reason: While sedatives may be used to manage acute distress, this response does not address the client's expressed feelings of hopelessness and the risk of self-harm.

Choice C reason: This response directly addresses the client's statement about not wanting to live, which could indicate suicidal ideation. It is important to assess for the risk of self-harm or suicide.

Choice D reason: This response may be helpful in a long-term plan but does not address the immediate risk of harm to the client. It is also not guaranteed that a family member can obtain custody.

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Correct Answer is B

Explanation

Choice A reason: This response may seem dismissive and could minimize the client's feelings. It's important to acknowledge the client's emotions as valid and unique to their experience, rather than comparing them to others.

Choice B reason: This response invites the client to share their feelings in a non-judgmental space and shows the nurse's willingness to listen. It respects the client's autonomy and provides an opportunity for them to open up about their concerns at their own pace.

Choice C reason: While this response is meant to be reassuring, it may inadvertently invalidate the client's feelings. Embarrassment is a personal emotion, and what might seem trivial to one person can be significant to another.

Choice D reason: This response implies that sharing will lead to relief, which may not always be the case. It also puts pressure on the client to disclose information before they are ready, which could be counterproductive.

A. The client appears to be well-groomed B. The client’s current weight is 54 kg (119 lb.) C. The client states they are sleeping 5 to 6 hours per night, but having an occasional nightmare D. The client verbalizes a decreased appetite and gastrointestinal discomfort E. The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.” F. The client verbalizes that bullying experienced during high school has led to anxiety G. The client engages in thought-stopping behavioral therapy and cognitive restructuring H. The client reports taking escitalopram 20 mg daily, 2 hours after breakfast

Correct Answer is ["A","C","G","H"]

Explanation

Being well-groomed can be an indicator of improved mental health, as it suggests the client is taking care of their personal hygiene and appearance, which can be neglected during severe anxiety episodes.

An increase in the amount of sleep and a decrease in the frequency of nightmares can be seen as an improvement in the client’s condition, as sleep disturbances are common in anxiety disorders.

Engagement in thought-stopping behavioral therapy and cognitive restructuring indicates that the client is actively participating in therapeutic activities designed to manage anxiety, which is a positive sign of improvement.

Consistent medication adherence, as reported by the client taking escitalopram 20 mg daily, is crucial for managing anxiety symptoms and indicates the client’s commitment to following the treatment plan.

The client’s weight remaining stable could be neutral, as it does not indicate a significant change. Verbalizing decreased appetite and gastrointestinal discomfort, feeling anxious about leaving the house, and stating that past bullying has led to anxiety are all signs that the client is still experiencing symptoms of anxiety. Therefore, these choices do not reflect an improvement in the client’s condition.

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A nurse is caring for a client who has a substance use disorder. The client states, "The state took my child away after my overdose. I don't want to go on living without them." Which of the following therapeutic responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

Correct Answer is ["A","C","G","H"]

Explanation

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