A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?
"Come with me to an area where we can talk without interruption."
"Providers usually recommend relaxation exercises for clients who are as upset as you are."
"An antianxiety pill works best for situations like this."
"Most clients with anxiety issues benefit from lying down.".
The Correct Answer is A
The correct answer is choice A: "Come with me to an area where we can talk without interruption."
Choice A rationale:
The nurse's response of inviting the client to a quieter area for conversation demonstrates therapeutic communication. By offering a private space, the nurse acknowledges the client's distress and creates an environment conducive to open discussion. This response allows the client to express their feelings without the pressure of being observed or interrupted, fostering a sense of safety and trust.
Choice B rationale:
This response suggests recommending relaxation exercises, which might not be appropriate for a client in a heightened state of anxiety. While relaxation techniques can be helpful for managing anxiety, the client's current level of distress requires immediate attention and active engagement rather than advice on future interventions.
Choice C rationale:
Mentioning an antianxiety pill oversimplifies the situation and ignores the importance of therapeutic communication. Medication is not the primary intervention at this moment, and assuming that a pill would be the immediate solution could diminish the client's need to express their feelings and concerns.
Choice D rationale:
Suggesting that most clients with anxiety issues benefit from lying down is an inaccurate generalization. Different individuals have varying coping mechanisms, and the client's pacing and rambling indicate a need for active support and conversation, rather than a one-size-fits-all approach of lying down.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "You may experience dizziness upon standing while taking this medication."
Choice A rationale:
This choice is the correct answer because haloperidol, an antipsychotic medication, can cause orthostatic hypotension, which leads to dizziness upon standing. Antipsychotic medications often affect blood pressure regulation and can result in a sudden drop in blood pressure when transitioning from sitting or lying down to standing. This explanation provides essential information to the client to help them understand potential side effects and take necessary precautions.
Choice B rationale:
This choice is incorrect. Haloperidol is not indicated for treating symptoms of obsessive-compulsive disorder (OCD). It is primarily used to manage symptoms of schizophrenia and other psychotic disorders. Providing false information about its indications is not appropriate and may lead to confusion.
Choice C rationale:
This choice is incorrect. Clients should never stop taking antipsychotic medications abruptly without consulting their healthcare provider. Discontinuing such medications can lead to withdrawal effects and a worsening of symptoms. Encouraging the client to stop the medication if side effects are bothersome is not appropriate and could potentially jeopardize their well-being.
Choice D rationale:
This choice is partially correct but not the best answer. While haloperidol can cause excessive salivation (sialorrhea) as a side effect, the primary concern in this situation should be related to orthostatic hypotension and dizziness upon standing. Mentioning excessive salivation would be helpful, but it's secondary to the risk of falls associated with orthostatic hypotension.
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.
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