A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

it will help you feel better if you talk about it

"Come on out and get involved with the game the other clients are playing

"Til stay with you for a few minutes."

Till come back when you feel like talking."

Answer and Explanation

The Correct Answer is C

A. "It will help you feel better if you talk about it." While talking can be therapeutic, pushing the client to talk when they're not ready may be counterproductive and increase their distress.

B. "Come on out and get involved with the game the other clients are playing." Encouraging the client to engage in activities may not be suitable when she is expressing a need for solitude and is not ready to participate.

C. "I'll stay with you for a few minutes."
This response reflects the nurse's willingness to provide support without pressuring the client to talk. It acknowledges the client's feelings and offers a comforting and nonintrusive presence. It respects the client's desire for solitude while still showing empathy and availability.

D. "I'll come back when you feel like talking." This response leaves the client alone, which may
be appropriate if that's what the client prefers. However, offering to stay for a few minutes communicates immediate support without pressure.

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Correct Answer is C

Explanation

A. Planning with the client for how he can better handle frustration (option A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.

B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.

C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.

D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.

A. Uncontrolled movements around the mouth B. Seizures and tremors C. Nause And vomiting D. Hallucinations and delusions

Correct Answer is A

Explanation

A. Uncontrolled movements around the mouth.
Tardive dyskinesia is a side effect associated with the long-term use of antipsychotic medications, especially first-generation or typical antipsychotics. It is characterized by involuntary, repetitive movements, often involving the face, such as uncontrolled movements around the mouth (e.g., lip smacking, puckering, chewing).

B. Seizures and tremors are not typical adverse effects of tardive dyskinesia. They are more commonly associated with other side effects or conditions.

C. Nausea and vomiting are not typically associated with tardive dyskinesia. These symptoms may be side effects of antipsychotic medications, but they are not characteristic of tardive dyskinesia itself.

D. Hallucinations and delusions are not associated with tardive dyskinesia. Tardive dyskinesia primarily involves involuntary movements and is not related to changes in thought content or perception.

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A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

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A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?