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

“Why are you feeling so down?"

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

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

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

Answer and Explanation

The Correct Answer is B

A. "Why are you feeling so down?"

This response could come across as confrontational or invasive, potentially making the client feel uncomfortable. The client has already expressed their desire not to talk at the moment, so pushing for an explanation may not be well-received.

B. "I’ll just sit here with you for a few minutes then."

Explanation:

This response shows empathy and support without pushing the client to talk or sharing personal experiences. It respects the client's desire for space and acknowledges their emotions without being intrusive. It provides a calming and non-intrusive presence, giving the client the option to open up if and when they are ready.

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

While sharing personal experiences can sometimes be helpful, in this context, it might inadvertently shift the focus from the client's emotions to the nurse's experiences. It's important to keep the focus on the client and their feelings.

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

Suggesting that talking might help is well-intentioned, but it might pressure the client into discussing their feelings when they have clearly stated their preference not to at that moment. The client's autonomy and comfort should be respected.

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Correct Answer is B

Explanation

A. Helping the client identify positive personality traits.

While addressing self-esteem and positive personality traits is valuable for the client's overall well-being, it is not the immediate priority during the detoxification phase. Ensuring physiological safety comes first.

B. Providing for adequate hydration and rest.

Explanation: The detoxification process from alcohol can result in withdrawal symptoms that range from mild discomfort to severe medical complications. Adequate hydration and rest are essential during this phase to manage withdrawal symptoms and prevent potential complications such as dehydration, electrolyte imbalances, and seizures. Maintaining the client's physiological stability is of utmost importance.

C. Educating the client about the consequences of alcohol misuse.

Providing education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but it's not the primary concern during the initial detoxification phase.

D. Confronting the use of denial and other defense mechanisms.

Addressing denial and defense mechanisms is important for therapy, but it might not be the immediate priority. Physiological stabilization through hydration and rest takes precedence in the detoxification phase.

A. Explain the client that the behavior was unacceptable. B. Explore the truth of the client's statements. C. Set behavioral limits for the client. D. Establish a client relationship

Correct Answer is C

Explanation

A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.

B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.

C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.

D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.

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

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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