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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lanugo refers to fine, soft hair that grows on the face, back, and arms as a result of malnutrition. It is more common in anorexia nervosa rather than bulimia nervosa.
B. Muscle wasting is not typically a primary symptom of bulimia.
C. Hypomagnesemia, or low magnesium levels, may occur but is not very characteristic of bulimia nervosa.
D. Hypokalemia, or low levels of potassium in the blood, is a common finding in individuals with bulimia nervosa who engage in purging behaviors such as vomiting or misuse of diuretics. Potassium is crucial for proper muscle and nerve function, and low levels can lead to symptoms such as muscle weakness, fatigue, cardiac arrhythmias, and in severe cases, paralysis.
Correct Answer is D
Explanation
A. The PSDA applies to all adult clients regardless of age. It ensures that adults have the right to make decisions about their medical care, including the right to accept or refuse treatment, regardless of whether they are elderly or not. Age is not a factor in the applicability of the PSDA.
B. While it's common for a living will to be witnessed, it is not a legal requirement under the PSDA.
C. Advance directives are applicable to all clients, including those receiving mental health care.
D. The Patient Self-Determination Act (PSDA) ensures that adult patients are informed about their rights to make decisions regarding their medical care, including the right to accept or refuse treatment and to prepare an advance directive.
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