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: Telling the client that the symptoms will improve over time without further assessment could be misleading. These symptoms could indicate lithium toxicity, which requires immediate medical attention.

Choice B reason: Lethargy, muscle weakness, and blurred vision can be signs of lithium toxicity. The nurse should recommend blood tests to check lithium levels and kidney function to rule out toxicity.

Choice C reason: Decreasing sodium intake is not recommended without a healthcare provider's advice, as sodium levels can affect lithium levels in the body. Sudden changes in sodium intake should be avoided unless directed by a healthcare provider.

Choice D reason: Continuing the medication as prescribed without addressing the symptoms could be dangerous. The symptoms reported by the client need to be evaluated to ensure they are not due to lithium toxicity.

A. Identify the client's stressors. B. Talk to the client using short, simple sentences. C. Speak to the client in a loud voice. D. Request that security guards restrain the client. E. Stand directly in front of the client.

Correct Answer is ["A","B"]

Explanation

Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.

Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.

Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.

Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.

Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.

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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 is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

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