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 B
Explanation
The correct answer is choice B: "Tell me more about your concerns about taking chemotherapy."
Choice A rationale:
This response focuses on negative outcomes and might discourage the client from exploring her options. It does not support the client's autonomy or address her concerns about nontraditional treatments. The nurse's role should be to facilitate open communication and understanding.
Choice B rationale:
This response is the most therapeutic. By inviting the client to share her concerns, the nurse demonstrates empathy and encourages the client to express her thoughts and feelings. This approach fosters a collaborative and respectful relationship, allowing the nurse to address the client's worries effectively.
Choice C rationale:
This response is directive and dismissive of the client's wishes. It fails to consider the client's perspective and autonomy. The nurse should avoid imposing personal opinions and instead promote a patient-centered approach.
Choice D rationale:
While acknowledging the provider's expertise is important, this response does not address the client's concerns about nontraditional treatments. It's essential to focus on the client's individual preferences and provide information to help her make an informed decision.
Correct Answer is B
Explanation
Choice A rationale:
Reviewing the client's toxicology laboratory report is not the priority action in this situation. While assessing toxicology can provide valuable information, the immediate concern is the client's safety due to their admission of thoughts of self-harm with a plan. Toxicology can be relevant but addressing the immediate risk takes precedence.
Choice B rationale:
Initiating suicide precautions is the priority action in this case. The client's admission of thoughts of self-harm with a plan indicates a high risk for suicide. Suicide precautions involve closely monitoring the client, removing any potential means of self-harm, and providing a safe environment. Addressing the client's immediate safety is of utmost importance.
Choice C rationale:
Making a contract with the client for eating behavior is not the priority action in this situation. While eating behavior might be a concern for some individuals with borderline personality disorder, depression, and substance abuse, the client's current statement about self-harm takes precedence. Ensuring the client's safety comes before addressing other aspects of their care.
Choice D rationale:
Administering the Hamilton Depression Scale is not the priority action in this scenario. While assessing the severity of the client's depression is important, the immediate concern is their safety due to the expressed thoughts of self-harm. Once the client's safety is ensured, further assessment and evaluation can take place.
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