A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?
"Have you tried leaving your house just once per day?"
"Have you thought about moving to a new neighborhood?"
"Let's discuss how you feel when you leave your house."
"Tell me why you have developed an aversion to leaving your house."
The Correct Answer is C
Choice A Reason:
"Have you tried leaving your house just once per day?" This response assumes a potential solution without fully understanding the client's feelings. It doesn't encourage open discussion or exploration of the client's anxiety.
Choice B Reason:
"Have you thought about moving to a new neighborhood?" This response jumps to a significant life change as a solution without exploring the client's current situation and emotions. It may not be a practical or necessary step.
Choice C Reason:
"Let's discuss how you feel when you leave your house." This response is an open and therapeutic approach that encourages the client to express their feelings and thoughts about the situation. It allows the nurse to gather more information and better understand the client's anxiety related to leaving the house. The other options do not facilitate open communication or exploration of the client's feelings.
Choice D Reason:
"Tell me why you have developed an aversion to leaving your house." While this response is more open-ended, it phrases the question in a somewhat confrontational manner, which might make the client defensive. The previous response ("Let's discuss how you feel when you leave your house") is gentler and inviting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Abnormal Involuntary Movement Scale is correct. The Abnormal Involuntary Movement Scale (AIMS) is a standardized tool used to assess and identify tardive dyskinesia, a side effect of antipsychotic medications. Tardive dyskinesia involves involuntary, repetitive movements, typically involving the face, mouth, and sometimes other body parts. Regular monitoring using the AIMS helps healthcare providers detect and evaluate the severity of these abnormal movements, allowing for appropriate management and intervention as needed.
Choice B Reason:
Mental Status Examination (MSE) is incorrect. The MSE is a comprehensive assessment of a person's mental state and cognitive function. While it is valuable for assessing a person's overall mental health and cognitive status, it is not specific for identifying tardive dyskinesia, which is a specific movement disorder.
Choice C Reason:
Brief Psychiatric Rating Scale (BPRS) is incorrect. The BPRS is a tool used to assess the severity of psychiatric symptoms and their changes over time. It is not specific for identifying the physical movements associated with tardive dyskinesia.
Choice D is incorrect:
Patient Health Questionnaire (PHQ) is incorrect. The PHQ is a self-report tool used to screen for symptoms of depression and anxiety. It is not designed for identifying movement disorders like tardive dyskinesia, which are characterized by abnormal physical movements.
Correct Answer is A
Explanation
Choice A Reason:
"I should discuss this document with my family after I sign it. “This statement is accurate because it reflects the importance of discussing the advance directive document and the client's preferences with their family and healthcare providers after it has been signed. Advance directives are not set in stone, and clients can change their preferences or modify their advance directives if needed. It is essential for healthcare providers and family members to be aware of the client's wishes regarding medical decisions in case they are unable to communicate or make decisions in the future.
Choice B Reason:
"An attorney will need to notarize this document for it to be valid." While it's true that some legal documents may require notarization, advance directives typically don't need to be notarized to be valid. They often require witnesses rather than notarization.
Choice C Reason:
"I am not allowed to change my mind once I sign this document. “This statement is not accurate. Clients can change their minds and modify their advance directives at any time, as long as they have the capacity to do so. Advance directives are intended to reflect a person's current healthcare preferences.
Choice D Reason:
"My partner needs to be present when I sign this document." While it's important for the client to discuss their advance directives with their family or loved ones, the presence of a partner is not a requirement for the document to be valid. Advance directives primarily focus on the individual's healthcare preferences and choices.
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