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
Explanation
The correct answer is choice C.
Choice A rationale:
Planning a therapeutic diet is important for overall client care, but it might not be the first priority. The client's significant weight loss and distorted body image require more immediate attention to address potential underlying mental health concerns..
Choice B rationale:
Providing a structured environment is beneficial, but it might not be the first priority in this situation. The client's distorted perception of weight and significant weight loss necessitate more immediate assessment and intervention.
Choice C rationale:
Assessing the client's nutritional status is the first priority in this scenario. The client's weight loss of 11 kg (25 lb) over 3 months and belief that she is fat are indicators of a possible eating disorder. Nutritional assessment helps determine the severity of the issue and guides appropriate interventions.
Choice D rationale:
While requesting a mental health consult is important, it is not the first priority. Addressing the client's immediate physical health, which includes assessing her nutritional status and potential risk for complications related to her distorted body image, takes precedence.
Correct Answer is D
Explanation
The correct answer is choice D. A child whose parents answer questions for the child.
Choice A rationale:A child with a BMI indicating obesity is not necessarily a sign of abuse. Obesity can result from various factors, including genetics, diet, and lifestyle. While it is important to address obesity for the child’s health, it does not directly indicate abuse.
Choice B rationale:A child who uses the call light frequently may be seeking attention or reassurance, but this behavior alone does not indicate abuse. Frequent use of the call light can be due to anxiety, fear, or a need for comfort, which can be addressed through appropriate nursing care and support.
Choice C rationale:A child who has frequent visitors is generally seen as having a strong support system. Frequent visits from family and friends usually indicate that the child is well-cared for and loved. This is not typically a sign of abuse.
Choice D rationale:A child whose parents answer questions for the child can be a red flag for abuse. This behavior may indicate that the parents are controlling and do not allow the child to speak for themselves, which can be a sign of emotional or psychological abuse. It is important for healthcare providers to observe interactions between the child and parents and assess for any signs of coercion or control.
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