A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he 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?

"Most clients with anxiety issues benefit from lying down."

"An antianxiety pill works best for situations like this."

"Providers usually recommend relaxation exercises for clients who are as upset as you are."

"Come with me to an area where we can talk without interruption."

Answer and Explanation

The Correct Answer is D

This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.

A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.

B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.

C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.

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Correct Answer is D

Explanation

Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.

A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.

B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.

C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.

A. "Why are you feeling so down?" B. "It might help you feel better if you talk about it." C. "I understand. I've felt like that before, too." D. "I'll just sit here with you for a few minutes then."

Correct Answer is D

Explanation

This response acknowledges the client's feelings and respects their desire for space and silence. By offering to sit with the client, the nurse provides a comforting presence without pressuring the client to talk or share their emotions. It shows understanding and support for the client's current emotional state.

The other options may not be as helpful in this situation:

A- "Why are you feeling so down?" can be seen as intrusive and may make the client feel defensive or overwhelmed. It's important to respect the client's boundaries and not push them to explain their feelings if they are not ready.

B- "It might help you feel better if you talk about it." While talking about feelings can be beneficial for some individuals, it should be done on the client's terms. Pressuring the client to talk about their emotions may create additional distress.

C- "I understand. I've felt like that before, too." While sharing personal experiences can be a way to establish rapport, it should be done cautiously and with consideration for the client's unique situation. In this case, the focus should be on the client's needs rather than the nurse's experiences.

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A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he 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

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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