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 D

Explanation

A. Joining a group discussion about a local election: While group discussions can be productive, a person in the manic phase of bipolar disorder may have difficulty focusing and may become overly talkative or agitated. Engaging in a group discussion about a local election may exacerbate their symptoms and lead to increased energy and agitation.

B. Watching a video with a group in the day room: Watching a video in a group setting may not be suitable for a person in the manic phase, as they might find it hard to sit still and concentrate. The fast-paced and changing nature of videos may contribute to increased restlessness and agitation.

C. Participating in a basketball game in the gym: Engaging in physical activities like basketball can be too stimulating for someone in the manic phase. Their heightened energy levels may cause them to become overly competitive, agitated, or impulsive, potentially leading to risky behavior or increased symptoms.

D. Walking with the nurse in the courtyard: Taking a walk in a calm and soothing environment, such as a courtyard, can help a person in the manic phase expend excess energy in a controlled manner. Walking provides physical activity without overstimulating or overwhelming the individual, making it a more appropriate choice to address boredom while managing their symptoms.

A. Provide an activity schedule that changes from day to day. B. Rotate assignment of daily caregivers. C. Limit time for the client to perform activities. D. Talk the client through tasks one step at a time

Correct Answer is D

Explanation

A. Providing an activity schedule that changes from day to day might be overwhelming and confusing for a client with Alzheimer's disease, as routine and predictability are often more beneficial.

B. Constantly rotating caregivers can lead to increased confusion for the client, as familiarity and consistency are important in their care.

C. Limiting time for the client to perform activities can add unnecessary stress and may not be conducive to a comfortable and supportive environment for someone with Alzheimer's disease.

D. Talk the client through tasks one step at a time.

For a client with Alzheimer's disease, providing clear and simple instructions is crucial. Breaking tasks down into manageable steps helps the client follow and complete activities more effectively. This approach reduces confusion and frustration and promotes the client's ability to engage in activities of daily living.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the use to suggest to this client?

Correct Answer is D

Explanation

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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