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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.
Incorrect:
B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.
C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.
D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.
Correct Answer is B
Explanation
This response acknowledges the client's effort and self-care without making assumptions or imposing judgment. It is an open and non-intrusive statement that shows the nurse is paying attention to the client's appearance and recognizing their positive action of self-grooming. It allows the client to share their feelings or thoughts if they choose to without feeling pressured or judged. This response demonstrates empathy and understanding, creating a supportive and non-threatening environment for the client to express themselves if they wish to do so.
Incorrect:
A- "Why are you all dressed up today?" This question may put the client on the spot and make them feel self-conscious or defensive. It assumes that there must be a specific reason for the client's appearance, which may not be the case. It can also imply that the client's usual appearance is different or not as desirable.
C- "Everyone feels better after showering." While it is true that personal hygiene can have a positive impact on one's mood, this statement may come across as dismissive or oversimplifying the client's experience. It may invalidate any underlying emotions or struggles the client is facing with their depression. It is important to acknowledge and address the client's feelings rather than making broad generalizations.
D- "You must be getting better. You look great." This statement assumes that physical appearance is directly correlated with the client's mental health and suggests that improvement in appearance equates to improvement in mental well-being. However, a person's outward appearance may not accurately reflect their internal struggles or progress in managing depression. Additionally, it can create pressure for the client to maintain a certain appearance to be perceived as "better."
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