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

"It might help you feel better if you talk about it."

“Why are you feeling so down?"

“I just sit here with you for a few minutes then."

"I understand. I've felt like that before, too."

Answer and Explanation

The Correct Answer is C

The appropriate response for the nurse in this situation would be: "I'll just sit here with you for a few minutes then."
This response acknowledges the client's expressed desire not to talk and respects their boundaries. It shows support and presence by offering companionship without pressuring the client to discuss their feelings. The nurse's willingness to sit with the client demonstrates empathy and provides a sense of comfort and reassurance.
The other options are not as appropriate:

1.   "It might help you feel better if you talk about it." This response disregards the client's stated preference not to talk and may create a sense of pressure or intrusiveness. It is important to respect the client's autonomy and readiness to share their feelings.
2.   "Why are you feeling so down?" This response directly asks the client to explain their feelings, which they have already indicated they do not want to discuss. It can be seen as intrusive and may make the client feel uncomfortable or defensive.
3.   "I understand. I've felt like that before, too." While empathy is important, this response brings the focus back to the nurse's own experiences, potentially diverting the attention from the client. It is important for the nurse to remain focused on the client's needs and create a supportive environment for them to express their feelings if they choose to do so.

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Correct Answer is B

Explanation

By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.

Let's review the other options and explain why they are not appropriate in this situation:

A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.

C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.

D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.

A. "A psychiatrist determines that the client's behavior is irrational. B. "The client is unable to manage the affairs necessary for daily life." C. "The client's behavior is a threat to self or others. D. "The client has been accused of breaking the law."

Correct Answer is C

Explanation

Involuntary commitment is a legal process where an individual is admitted to a psychiatric facility against their will due to a perceived risk of harm to themselves or others. The primary concern in involuntary commitment is the safety and well-being of the individual and those around them.

Therefore, it is important for the nurse to inform the client's family about the reason for the involuntary commitment, emphasizing that the client's behavior poses a threat to themselves or others.

incorrect:

A. "A psychiatrist determines that the client's behavior is irrational." This statement focuses on the client's behavior being irrational, which is not the primary criteria for involuntary commitment. It is more important to emphasize the potential harm the client may cause to themselves or others.

B. "The client is unable to manage the affairs necessary for daily life." While this may be a factor contributing to the need for psychiatric treatment, it is not the specific reason for involuntary commitment. The main concern is the risk of harm associated with the client's behavior.

D. "The client has been accused of breaking the law." Involuntary commitment is not based on accusations of breaking the law. It is primarily focused on the safety and well-being of the individual and the potential risk they pose to themselves or others.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse is caring for a client who has been admitted Involuntarily for psychiatric treatment. Which of the following Information about involuntary commitment should the nurse provide the client's family?

Correct Answer is C

Explanation

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