A nurse is sitting with a client and asks how the client is feeling. The client replies, "Who would feel anything but rotten in my position?" Which of the following actions should the nurse take?

Sympathize with the client's situation.

Observe the client's nonverbal behaviors.

Remind the client that they will feel better in a few days.

Ignore the client's negative response and leave the room.

Answer and Explanation

The Correct Answer is B

A. Sympathize with the client's situation: Expressing sympathy may seem supportive, but it can reinforce the client’s negative outlook rather than promote exploration of feelings or problem-solving. It may also shift focus away from objective assessment of the client’s emotional state.

B. Observe the client's nonverbal behaviors: Nonverbal cues such as facial expressions, posture, and gestures provide important information about the client’s emotional state and level of distress. Observing these behaviors helps the nurse assess mood, affect, and potential risk factors while planning appropriate interventions.

C. Remind the client that they will feel better in a few days: Offering reassurance without first understanding the client’s feelings can minimize their experience and may reduce trust. Immediate reassurance is less therapeutic than assessing and validating the client’s current emotional state.

D. Ignore the client's negative response and leave the room: Ignoring the client’s expression of distress is inappropriate and can damage rapport. It prevents the nurse from gathering essential information needed for emotional support and intervention planning.

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Correct Answer is B

Explanation

A. "I'm uncomfortable when people tell sexually explicit jokes.": Discomfort with sexually explicit jokes reflects personal boundaries and social comfort, but it does not indicate a concern about the client’s own sexuality or sexual function.

B. "I feel like my ability to perform sexually has changed since I've gotten older.": This statement directly expresses a concern about sexual function and performance, indicating the client may be experiencing changes in libido, arousal, or sexual satisfaction. It signals the need for assessment and counseling regarding sexual health.

C. "I have the same level of sexual desire for my partner as I did in the past.": Maintaining sexual desire suggests that the client does not have current concerns about sexuality. It reflects stability in sexual function rather than a problem or worry.

D. "I've been with the same sexual partner for 13 years.": Duration of a relationship provides context about the client’s sexual history but does not indicate a current concern regarding sexuality. It is descriptive rather than indicative of distress or issues.

A. "Would you like me to get some medication to calm you down?" B. "You don't work anymore. Let's go sit down and talk." C. "Would you like to go to your room for a nap now?" D. "I'll walk with you for a while. Tell me about your work."

Correct Answer is D

Explanation

A. "Would you like me to get some medication to calm you down?": Offering medication immediately does not address the underlying anxiety or disorientation. Non-pharmacologic interventions should be attempted first in clients with Alzheimer’s disease unless safety is at immediate risk.

B. "You don't work anymore. Let's go sit down and talk.": Confronting the client with reality can increase confusion, anxiety, and agitation. Clients with Alzheimer’s disease respond better to validation rather than correction of their perceptions.

C. "Would you like to go to your room for a nap now?": Redirecting to rest may help in some situations, but it does not validate the client’s feelings or engage them in a meaningful way. The client may resist if the suggestion does not acknowledge their current concern.

D. "I'll walk with you for a while. Tell me about your work.": Walking alongside the client and engaging in conversation validates their feelings, reduces agitation, and provides safe physical activity. This approach supports emotional connection, reduces anxiety, and prevents escalation of behavioral symptoms.

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A nurse is sitting with a client and asks how the client is feeling. The client replies, "Who would feel anything but rotten in my position?" Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is seeking counseling at a mental health clinic. The nurse should identify that which of the following client statements indicates a client concern about sexuality?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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