A nurse is taking care of an adult client who is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

"How long has this been going on?".

"It sounds like you're having a difficult time.".

"Have you talked to your parents about this yet?".

"Why do you think you are so anxious?".

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. "It sounds like you're having a difficult time."

Choice A rationale:

"How long has this been going on?" This question focuses on the duration of the client's symptoms, which might not be the most appropriate response at this point. The client's immediate emotional state and distress should be acknowledged before delving into the duration of the issue.

Choice B rationale:

"It sounds like you're having a difficult time." This response demonstrates empathy and understanding towards the client's emotional state. It acknowledges the client's feelings without making assumptions or probing for specific details. It provides a supportive environment for the client to open up further.

Choice C rationale:

"Have you talked to your parents about this yet?" This question assumes that the client's parents are a source of support and that the client has not yet spoken to them about their feelings. It also directs the conversation towards external parties instead of focusing on the client's immediate emotions.

Choice D rationale:

"Why do you think you are so anxious?" This question might come across as confrontational or demanding, potentially making the client defensive. It could hinder open communication and create a barrier between the nurse and the client.

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Correct Answer is C

Explanation

Choice A rationale:

This choice describes tertiary prevention, which focuses on minimizing the consequences of an existing disorder or preventing further deterioration. It is not directly related to primary prevention, which addresses the prevention of the onset of disorders.

Choice B rationale:

This choice corresponds to secondary prevention, which involves early intervention to minimize the impact of an illness that has already begun. It aims to reduce the prevalence and duration of the illness but is not the primary focus of primary prevention.

Choice C rationale:

The correct choice. Primary prevention focuses on reducing the incidence of mental disorders within the population. It involves strategies that target the entire population or specific high-risk groups to prevent the initial development of mental health issues. These strategies may include public health campaigns, education, and interventions to promote mental well-being and resilience.

Choice D rationale:

This choice describes the process of early identification and initiation of treatment, which is a component of secondary prevention. It aims to prevent the progression of existing problems rather than preventing the initial development of mental disorders.

A. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F). B. A client attempts to climb out of bed and repeatedly states she must get home. C. A client refuses to get out of bed and has no motivation to attend to daily hygiene. D. A client wants to know the current time while there is a clock on the wall.

Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

A client requesting extra blankets due to a room temperature discrepancy is not indicative of delirium. This behavior may simply stem from feeling cold, which is a logical response to a temperature below the client's comfort level.

Choice B rationale:

A client attempting to climb out of bed and repeatedly stating a need to get home is a manifestation of delirium. Delirium is characterized by sudden disturbances in consciousness and cognitive function, leading to confusion and altered perception. The client's behavior suggests a disoriented state and a distorted perception of reality.

Choice C rationale:

A client refusing to get out of bed and lacking motivation for daily hygiene might not necessarily indicate delirium. These symptoms could be related to other factors, such as depression or physical discomfort, which are not specific to delirium.

Choice D rationale:

A client wanting to know the current time when there is a visible clock on the wall doesn't indicate delirium. It might just reflect the client's desire to know the time, which is a common behavior and doesn't directly relate to cognitive disturbances associated with delirium.

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A nurse is taking care of an adult client who is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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