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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Free Nursing Study Resources

Correct Answer is ["2.5"]

Explanation

To administer the correct dose of sertraline, which is 50 mg, when the available oral solution concentration is 20 mg/mL,

Volume = Dose / Concentration.

So, for a 50 mg dose using a 20 mg/mL solution, the calculation would be 50 mg divided by 20 mg/mL, resulting in 2.5 mL.

Therefore, the nurse should administer 2.5 mL of the sertraline oral solution.

A. Timeout B. Restraint C. Diversion D. Therapeutic hold

Correct Answer is A

Explanation

A. This technique involves allowing the client to remove themselves from the situation causing agitation temporarily. It is a de-escalation technique where the client can regain composure and reduce agitation by being alone or in a quieter environment. The nurse ensures the environment is safe and monitors the client during this time.
B. Restraint involves physically restricting the client's movement to prevent harm to themselves or others when they are in a state of extreme agitation and are at risk of causing harm. It is used as a last resort and typically requires a healthcare provider's order due to the potential risks and ethical considerations.
C. Diversion involves redirecting the client's attention away from the source of agitation to something else, such as a calming activity or a change of topic. It can help shift the client's focus and reduce escalating emotions.
D. Also known as a therapeutic restraint hold, this technique is used to safely manage a client who is agitated and may become physically aggressive. It involves trained staff using specific holds to restrain the client in a way that prevents harm while allowing for therapeutic communication.

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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 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.

Correct Answer is ["2.5"]

Explanation

A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de- escalation techniques in the client's medical record?

Correct Answer is A

Explanation

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