A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

"Tell me what is concerning you.”

"Crying helps us let things out and we feel better.”

"Your husband is making really good progress.”

"Did your husband say something to upset you?”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The correct choice. In this situation, the nurse's priority is to gather information and provide emotional support. By asking the spouse to share their concerns, the nurse opens up a channel of communication and shows empathy, creating an opportunity to address the spouse's worries and provide reassurance.

Choice B rationale:

While the sentiment that crying can be cathartic and relieving is true, this response does not directly address the spouse's concern or encourage them to share their feelings. It's important to focus on the spouse's feelings rather than just explaining the benefits of crying.

Choice C rationale:

Assuming that the husband is making progress without knowing the specifics of the situation can come across as dismissive of the spouse's concerns. It's important to validate the spouse's emotions and provide support, rather than making assumptions about the husband's progress.

Choice D rationale:

Asking whether the husband said something to upset the spouse might be relevant, but it does not address the spouse's expressed concern about their husband. This response may not foster open communication and emotional support as effectively as choice A.

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Correct Answer is C

Explanation

The correct answer is choice C. Walk with the client at a gradually slower pace.

Choice A rationale:

Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.

Choice B rationale:

Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.

Choice C rationale:

Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.

Choice D rationale:

Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.

A. Persecution. B. Erotomanic. C. Somatic. D. Control.

Correct Answer is B

Explanation

The correct answer is choice B. Erotomanic.

Choice A rationale:

Persecution. Persecutory delusions involve the belief that one is being targeted, harmed, or conspired against by others. This choice is not applicable in this scenario because the client is not expressing fear or belief that they are being persecuted.

Choice B rationale:

Erotomanic. Erotomanic delusions involve the false belief that someone, often of higher social status, is in love with the individual. In this case, the client's statement about being engaged to the Prince of England suggests an erotomanic delusion. The client is holding a grandiose belief that they are romantically involved with someone of prominence.

Choice C rationale:

Somatic. Somatic delusions involve the belief that there is something physically wrong with the individual's body. These delusions often manifest as the belief in having an illness or defect that is not actually present. The client's statement does not revolve around physical health or bodily concerns, making somatic delusion an unlikely option.

Choice D rationale:

Control. Control delusions involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This choice is not applicable in this scenario, as the client's statement does not indicate any perceived loss of control over their thoughts or actions.

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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with schizophrenia. The client states, "Did you know that I am engaged to the Prince of England?" The nurse should document that the client is experiencing which of the following types of delusions?

Correct Answer is B

Explanation

Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

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A nurse is caring for a client who is withdrawing from opioids. Which of the following medications would the nurse prepare to administer?

A charge nurse is preparing an educational session about addictive disorders for the nursing staff. Which of the following should the nurse include as etiological factors of addictive disorders? (Select all that apply).

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?