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 ["C","D"]
Explanation
The correct answer is choice c. Believes that others are deceiving him, and choice d.Continuously holds onto grudges
Choice A rationale:
Perceiving oneself as inferior to others is more characteristic of avoidant personality disorder, where individuals often avoid social situations due to feelings of inadequacy and fear of rejection.
Choice B rationale:
Desiring to be the center of attention is a trait often seen in histrionic personality disorder, where individuals crave attention and may use dramatic behavior to achieve it.
Choice C rationale:
Individuals with paranoid personality disorder tend to have a pervasive and unjustified mistrust of others. They often believe that others are deceiving, exploiting, or harming them, even in the absence of evidence to support these beliefs. This mistrust is a central characteristic of this disorder.
Choice D rationale:
Continuously holding onto grudges is another hallmark feature of paranoid personality disorder. These individuals are prone to bearing grudges and being unforgiving, as they are hypersensitive to perceived slights or insults.
Choice E rationale:
Exhibiting a grandiose sense of self-importance is more characteristic of narcissistic personality disorder, where individuals have an inflated sense of their own importance and often lack empathy for others.
Correct Answer is B
Explanation
The correct answer is choice B. Erotomanic.
Choice A rationale:
Persecution. Persecutory delusions involve the belief that one is being targeted, harmed, or conspired against by others. This choice is not applicable in this scenario because the client is not expressing fear or belief that they are being persecuted.
Choice B rationale:
Erotomanic. Erotomanic delusions involve the false belief that someone, often of higher social status, is in love with the individual. In this case, the client's statement about being engaged to the Prince of England suggests an erotomanic delusion. The client is holding a grandiose belief that they are romantically involved with someone of prominence.
Choice C rationale:
Somatic. Somatic delusions involve the belief that there is something physically wrong with the individual's body. These delusions often manifest as the belief in having an illness or defect that is not actually present. The client's statement does not revolve around physical health or bodily concerns, making somatic delusion an unlikely option.
Choice D rationale:
Control. Control delusions involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This choice is not applicable in this scenario, as the client's statement does not indicate any perceived loss of control over their thoughts or actions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.