A nurse is caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?
"Why did you feel like giving away your belongings?"
"You should find a support group to attend."
"Everyone feels a little down sometimes."
"Can you tell me how you have been feeling lately?"
The Correct Answer is D
A. "Why did you feel like giving away your belongings?"
This response is empathetic and invites the client to explore their feelings and motivations. It shows understanding and can help the nurse comprehend the client's emotional state better.
B. "You should find a support group to attend."
This response suggests a proactive step to seek support, which can be helpful. However, it might be premature in this context as the nurse hasn't fully assessed the client's situation yet. It's important to understand the client's feelings and circumstances before recommending specific interventions.
C. "Everyone feels a little down sometimes."
This response minimizes the client's feelings and can be invalidating. It doesn't acknowledge the seriousness of the client's statement, which might discourage them from opening up further.
D. "Can you tell me how you have been feeling lately?"
As previously explained, this response is empathetic and open-ended, encouraging the client to share their emotions and thoughts. It's a good starting point for a therapeutic conversation, allowing the nurse to assess the client's current mental state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.
B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.
C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.
D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.
Correct Answer is A
Explanation
A. Initiates social interactions with caregivers:One of the key goals for adolescents with autism spectrum disorder (ASD) is to improve social skills and interactions. Encouraging the adolescent to initiate social interactions is a positive and realistic outcome that promotes social development and enhances communication skills.
B. Meets own needs without manipulating others:While fostering independence and self-advocacy is important, adolescents with ASD may struggle with understanding social cues and may not manipulate others in a typical sense. This outcome may not be as relevant or achievable for the individual with ASD.
C. Changes behavior as a result of peer pressure:Adolescents with ASD may have difficulty understanding and responding to peer pressure in the same way as their neurotypical peers. This outcome may not be appropriate or realistic for someone with ASD, as it can lead to increased anxiety or discomfort.
D. Acknowledges that his delusions are not real:This outcome is more relevant to conditions such as schizophrenia or severe psychotic disorders, rather than ASD. Adolescents with autism may experience different cognitive challenges but generally do not have delusions in the way that individuals with psychotic disorders do.
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