A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?
Remain with the client.
Give to client a PRN sleeping medication,
Encourage the client to go back to bed.
Explore alternatives to pacing the floor with the client.
The Correct Answer is A
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give the client a PRN sleeping medication:
Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed:
Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client:
Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "I haven't gotten my period yet, and all my friends have theirs."
While the concern about not having gotten her period yet is a valid one, it's a common experience during adolescence. Variability in the timing of puberty is normal, and addressing this concern might involve providing reassurance and education about the natural range of development.
B) "There's a big pimple on my face, and I worry that everyone will notice it."
While concerns about physical appearance are common during adolescence, they are less urgent in terms of emotional and psychological well-being. Addressing body image issues is important, but the statement about lack of social acceptance and reciprocal liking indicates potentially deeper emotional challenges.
C) "None of the kids at this school like me, and I don't like them either."
Explanation:
Adolescence is a time of significant emotional and social development. The statement about not being liked by other students and not liking them in return indicates potential social isolation and difficulties in forming positive relationships. Adolescents often seek social acceptance and peer relationships are crucial for their well-being and development.
D) "My parents treat me like a baby sometimes."
This statement suggests a common parent-adolescent dynamic where there might be conflicts about independence and autonomy. While these feelings are valid, they don't necessarily reflect a higher priority concern related to social isolation and peer relationships.
Correct Answer is A
Explanation
A."You've been feeling that your life has no meaning."This response reflects active listening and acknowledges the client's emotions. Itreflects the client's feelings and encourages them to express more about their emotions and thoughts. It shows empathy and understanding, which can help build trust and rapport.
B. "You have a great deal to live for" may seem dismissive and does not address the client's current feelings of worthlessness.
C. "It's not unusual for depressed people to feel that way" can come across as minimizing the client's unique experience and does not provide support or encourage further discussion.
D. "Why do you feel you are worthless?" might make the client feel defensive or overwhelmed, and it does not offer the same level of empathy and support as reflecting their feelings would.
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