A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

Identify other housing options and sources of transportation.

Notify the facility chaplain to request scheduling an appointment.

Confirm that everything will be all right because belongings can be replaced.

Maintain eye contact with the client and summarize the client's feelings.

Answer and Explanation

The Correct Answer is D

Answer is d. Maintain eye contact with the client and summarize the client’s feelings.

a. Identify other housing options and sources of transportation: While it is essential to address practical needs such as housing and transportation for clients who have experienced a crisis like a house fire, it is not the immediate priority when the client is in acute emotional distress. In this scenario, the client is expressing emotional distress and may not be ready to focus on practical solutions. Therefore, addressing the client's emotional needs should take precedence over addressing practical concerns.

b. Notify the facility chaplain to request scheduling an appointment: While spiritual support can be beneficial for individuals coping with trauma or loss, it should not be the immediate response when a client is in acute emotional distress. While the chaplain's support may be sought later as part of the client's holistic care, it should not precede addressing the client's immediate emotional needs.

c. Confirm that everything will be all right because belongings can be replaced: This option is incorrect because it offers false reassurance and dismisses the client's feelings about their loss. While it is true that belongings can be replaced, the emotional impact of losing possessions, especially in a traumatic event like a house fire, should not be trivialized. The client's feelings of distress and uncertainty are valid and should be acknowledged and addressed by the nurse.

d. Maintain eye contact with the client and summarize the client’s feelings: Correct. This action demonstrates therapeutic communication, which is crucial in providing an atmosphere of support and safety for the client. Maintaining eye contact shows empathy, support, and advocacy, indicating to the client that their feelings are being heard and validated. Summarizing the client's feelings allows the nurse to demonstrate active listening and understanding, fostering trust and rapport between the nurse and client. By prioritizing the client's emotional needs, the nurse can help the client begin to process their feelings and move towards coping and problem-solving.

In summary, the correct answer is d because maintaining eye contact with the client and summarizing their feelings demonstrates therapeutic communication, which is essential in providing support and validation for the client's emotional distress. This approach allows the nurse to establish rapport and trust with the client, facilitating further therapeutic interventions and support.

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Correct Answer is D

Explanation

Choice A rationale:

Sweating is not an adverse effect commonly associated with buspirone (Buspar). While some side effects like dizziness, nausea, and headache might occur, sweating is not typically reported as a significant adverse effect of this medication.

Choice B rationale:

Decreased appetite is a potential adverse effect of buspirone (Buspar). However, it is not the most concerning in this context. Anxiety disorders like generalized anxiety disorder can lead to appetite changes, and while this should be monitored, it is not a priority compared to more severe adverse effects.

Choice C rationale:

Discolored urine is not a common adverse effect of buspirone (Buspar). Buspirone is primarily used to treat anxiety and does not usually cause changes in urine color. This effect is unrelated to the medication and likely has a different underlying cause.

Choice D rationale:

Hallucinations are a concerning adverse effect that should be reported to the provider. Hallucinations are not a typical side effect of buspirone and might indicate a more serious issue or an interaction with other medications. Reporting this symptom promptly is crucial to ensuring the client's safety and well-being.

A. The client responds to questions with disorganized speech. B. The client reports that voices are telling him to write a novel. C. The client's spouse reports that the client has recently gained weight. D. The client is dressed in all black.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. Clients may exhibit pressured speech, tangentiality, and flight of ideas, reflecting the heightened energy and cognitive disruptions associated with manic episodes.

Choice B rationale: Reporting auditory hallucinations, such as voices telling the client to write a novel, is more indicative of a psychotic disorder rather than acute mania in bipolar disorder. Mania typically involves elevated mood and activity levels, not hallucinations.

Choice C rationale: Weight gain reported by the spouse is not specific to acute mania. While changes in appetite and weight can occur in bipolar disorder, they are not defining features of manic episodes, which are characterized by heightened mood and activity.

Choice D rationale: Being dressed in all black does not specifically indicate acute mania. Mania is characterized by mood disturbances and increased activity levels rather than specific choices in clothing color, which can vary widely among individuals.

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A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking care of a client who has generalized anxiety disorder and is taking buspar (Buspirone). Which of the following adverse effects should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

Correct Answer is A

Explanation

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