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."
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The perception of family can vary among individuals, and it is important to respect the client's definition of family. By including people whom the client views as family, the nurse acknowledges the client's preferences and ensures that those who hold significance and provide support in the client's life are present during the interview.
Let's review the other options and explain why they may not be the most appropriate methods:
A. Include people who can support the client adequately: While it is important to involve individuals who can support the client, determining who can provide adequate support should be based on the client's perception and preference. The client's perspective on who can offer support may differ from the nurse's assessment, so it is crucial to involve individuals whom the client identifies as supportive.
B. Include people who live in the same house with the client: Proximity of residence does not necessarily determine the level of support or the client's perception of family. Including only individuals who live with the client may exclude other significant individuals in the client's life who may play a vital role in their support network.
D. Include people who are related to the client by blood and marriage: While blood relatives and family members by marriage can be important sources of support, it is not the sole criterion for inclusion. Clients may have chosen family or close friends who they consider to be their primary support system.
Correct Answer is A
Explanation
The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.
The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.
The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.
The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.
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