A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about he desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?

A) Have a staff member escort the client to her room:

Having a staff member escort the client to her room might be perceived as restrictive and could potentially escalate the client's anxiety. It's important to give the client some autonomy and not force them into isolation.

B) Allow the client to pace alone until physically tired:

While allowing the client to pace alone might seem like a non-intrusive option, it lacks the therapeutic engagement that can help the client feel supported and understood. It's important for the nurse to actively engage with the client to establish a therapeutic relationship.

C) Instruct the client to sit down and stop pacing:

Instructing the client to stop pacing could potentially increase their agitation and anxiety. Forcing the client to sit down against their wishes might lead to resistance and hinder the development of trust between the nurse and the client.

D) Walk with the client at a gradually slower pace:

This is the correct answer. Walking with the client at a gradually slower pace is a therapeutic approach that allows the nurse to build rapport, provide support, and help the client regulate their emotions. It respects the client's need for movement while also addressing their emotional state.

A. "Tell me who you think doesn't care about you."

Explanation: This response might come across as confrontational or defensive, which could discourage the client from opening up further. It's important to offer support and understanding rather than putting the client on the spot.

B. "Of course people care. Your family comes to visit every day."

Explanation: While it's true that the client's family visits, depression often distorts perception and emotions. Telling the client that people care might not be fully effective in addressing their feelings of worthlessness.

C. "Why do you feel that way?"

Explanation: This response opens the door for the client to express their emotions and thoughts. It encourages further conversation and helps the nurse understand the underlying causes of the client's feelings.

D. "I care about you, and I am concerned that you feel so sad."

Explanation: Correct Answer. This response shows empathy and genuine concern for the client's well-being. It acknowledges the client's emotions, offers support, and validates their feelings.