A nurse is collecting data from a client who states, "I am so worried about everything, and I can't seem to sit still, even when I eat." Which of the following responses should the nurse make?

"I don't understand why you're so upset."

"Don't worry. You'll feel better soon."

"Let's discuss what is bothering you."

"You need to eat to maintain your strength."

Answer and Explanation

The Correct Answer is C

A.   This response may come across as dismissive or lacking empathy. It does not acknowledge the client's feelings or address the underlying concerns contributing to their anxiety. It's important for the nurse to validate the client's emotions and provide reassurance rather than expressing confusion or disbelief.
B.   While this response aims to provide reassurance, it may oversimplify the client's feelings and situation. Anxiety is complex, and telling someone not to worry might not be effective in alleviating their distress. It's crucial to engage the client in a more meaningful conversation about their concerns and offer support tailored to their needs.
C.   This response demonstrates active listening and therapeutic communication. It encourages the client to express their worries and feelings, which can help them feel understood and supported. By discussing what is bothering them, the nurse can gather important information about the client's concerns and begin to address them effectively.
D.   While nutrition is important, this response may come across as directive and could potentially minimize the client's emotional distress. It does not acknowledge the client's anxiety or provide support for their current feelings of restlessness and worry. The nurse should prioritize addressing the client's emotional needs and anxiety before focusing on physical aspects like nutrition.

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Correct Answer is C

Explanation

A. A submissive personality alone is less likely to be a direct risk factor for becoming a perpetrator of child abuse. Individuals with a submissive personality tend to avoid confrontation and conflict rather than engage in aggressive or abusive behaviors towards others.
B. Being involved in community activities is generally a positive factor that promotes social engagement, support networks, and a sense of belonging. It does not inherently contribute to an increased risk of becoming a perpetrator of child abuse.
C. Low tolerance for frustration can be a risk factor for potential aggressive or impulsive behaviors. When individuals have difficulty managing frustration, they may be more prone to react impulsively or aggressively towards others, including children.

D. The absence of impulsive behaviors typically indicates better impulse control and decision-making abilities. Individuals who can regulate their impulses are less likely to engage in spontaneous or aggressive actions, including perpetrating child abuse.

A. "You must be mistaken. Snakes cannot be in the clinic." B. "Your provider requires this blood specimen." C. "I'm using a syringe to obtain your blood, not a snake." D. "I don't see a snake, but that must be scary for you."

Correct Answer is D

Explanation

A. This response dismisses the client's experience and hallucination as a mistake. It invalidates the client's feelings and does not acknowledge the client's reality. It can increase the client's distress and undermine trust in the nurse's communication.
B. While this statement provides factual information about the need for the blood specimen, it does not address the client's hallucination or their fear related to it. It may come off as indifferent to the client's feelings and concerns.
C. This option dismisses the client’s feelings without addressing them appropriately.
D. This response validates the client's experience and expresses empathy for their feelings of fear. It acknowledges the hallucination without confirming its reality and shows understanding of how

frightening the experience might be for the client. This response is supportive and helps build trust between the nurse and the client.

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A nurse is collecting data from a client who states, "I am so worried about everything, and I can't seem to sit still, even when I eat." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

Correct Answer is C

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?

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A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

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A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.