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.".

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Joining a bowling league 2 months ago indicates that the client is actively seeking social interactions and engaging in activities. While grief can manifest in various ways, joining a social activity does not necessarily indicate maladaptive grief. It's important for individuals to find ways to connect with others and continue living their lives after the loss of a loved one.

Choice B rationale:

Meeting his daughter for dinner every week demonstrates ongoing communication and emotional connection with family. This behavior suggests a healthy attempt at maintaining relationships and coping with the loss. Regular interactions with family members can be supportive during the grieving process.

Choice C rationale:

Keeping his partner's closet untouched since her death is a sign of maladaptive grief. This behavior suggests an inability to let go of personal belongings and move forward after a significant period of time. In healthy grieving, individuals usually work through their emotions and gradually start reorganizing their living spaces and personal items.

Choice D rationale:

Exercising at a local health facility 3 days each week indicates that the client is engaging in self-care and maintaining physical health. While exercise can be a coping mechanism, this behavior alone does not provide enough evidence to determine whether the client is experiencing maladaptive grief.

A. Ask the client direct questions about the hallucination. B. Act to the client as if the hallucination is real. C. Tell the client to go to their room and they should go away. D. Instruct the client to argue with the voices that are a part of the hallucination.

Correct Answer is A

Explanation

The correct answer is choice A. Ask the client direct questions about the hallucination.

Choice A rationale:

Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.

Choice B rationale:

Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.

Choice C rationale:

Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.

Choice D rationale:

Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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