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."
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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Related Questions
Correct Answer is B
Explanation
Heroin is an opioid drug that depresses the central nervous system, which can lead to respiratory depression. This means that heroin can slow down a person's breathing rate, potentially leading to shallow breathing or even stopping of breathing altogether. This is a life-threatening complication and one of the most significant dangers of heroin use.
The other options listed are associated with other substances or conditions:
A- Nasal septum perforation is commonly associated with the use of cocaine, not heroin.
C- Acute pancreatitis is not a commonly reported complication of heroin use.
D- Permanent short-term memory loss is not a specific complication of heroin use, though chronic substance abuse can lead to cognitive impairments and memory problems in general.
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.
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