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

This response reflects active listening and demonstrates empathy towards the client's feelings. It acknowledges the client's distress and encourages them to express their concerns and thoughts. By actively listening and showing genuine interest, the nurse can gather more information to assess the client's needs and determine the appropriate course of action.

Let's discuss why the other options are incorrect:

A. "Everything will be okay until morning. You can speak with your provider then." This response may dismiss or invalidate the client's current distress and fails to address their immediate concerns. It suggests waiting until morning without exploring the reasons behind the client's urgency.

C. "Go back to your room, and I'll try to get in touch with your provider in the morning." While the intention may be to offer assistance, this response does not address the client's emotional state or explore the reasons for their demand to see the provider. It may also not address the client's immediate needs and concerns.

D. "Why don't you wait until the morning? The provider will be available then." This response may come across as dismissive and may not acknowledge the client's current distress. It does not encourage the client to express their concerns or provide an opportunity for open communication.

A. Whether the client is unwilling to accept that treatment is needed. B. client is financially incapable of paying for prescribed medications. C. Whether the client is a danger to herself or others. D. Whether the client is unable to make arrangements to stay with someone.

Correct Answer is C

Explanation

When a client is involuntarily admitted to a mental health unit, there is typically a specific time frame, such as 72 hours, during which they can be held involuntarily for evaluation and
treatment. At the end of this initial hold period, further determination is required to determine if continued hospitalization is necessary.
The primary consideration for extending the client's stay is whether they continue to pose a danger to themselves or others. This determination is based on a comprehensive assessment of the client's mental state, behavior, and potential for harm. If the client still exhibits signs of being a threat to themselves or others, the healthcare team may decide to continue their hospitalization to ensure their safety and the safety of others.
The other options listed are not the primary criteria for determining the need for continued hospitalization:
● Whether the client is unwilling to accept that treatment is needed: While the client's willingness to accept treatment is an important factor, it is not the sole determinant for extending their stay. Even if the client recognizes the need for treatment, if they are still a danger to themselves or others, their hospitalization may be prolonged.
● Whether the client is financially incapable of paying for prescribed medications: Financial considerations do not directly impact the decision to extend the client's stay. The focus is on their safety and the need for continued psychiatric assessment and treatment.
● Whether the client is unable to make arrangements to stay with someone: The client's living arrangements or ability to stay with someone outside of the hospital are not the main factors in determining the need for extended hospitalization. The key consideration is whether the client continues to pose a danger 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 on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Correct Answer is C

Explanation

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