A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. What is the likely conclusion regarding the patient's behavior?

Patient is attempting to use relaxation strategies.

Patient is demonstrating withdrawal behaviors.

Patient is exhibiting clues to potential aggression.

Patient is trying to work through angry feelings.

Answer and Explanation

The Correct Answer is C

A.   Relaxation strategies involve deliberate and often structured activities aimed at reducing tension and stress, which isn't depicted in the described behavior.
B.   Withdrawal behaviors typically involve avoiding social interaction or retreating, which doesn't align with the observed actions.
C.   The described behavior, including pacing, clenching fists, and staring at a staff member, indicates potential signs of aggression or agitation.
D.   Working through angry feelings might involve communication or expression of emotions, but the described behavior leans more towards agitation and potential aggression.

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Correct Answer is A

Explanation

A. For a client with severe depression, a calm and direct approach is beneficial. Sitting with the client and offering simple, clear information can help establish trust and rapport.
B. Attending group therapy immediately might overwhelm the client, especially if they are newly admitted and experiencing severe depression.
C. Taking the client on a tour and introducing all staff members might be overwhelming or excessive for someone with severe depression.
D. While explaining unit policies is important, a direct informational approach might be more effective initially given the severity of the client's condition.

A. "I am glad you are feeling better. The team will consider your request." B. "Because we are concerned about your safety, we will continue with our plan." C. "I wonder what this sudden change is all about. Please tell me more." D. "You should not try to direct your care. Leave that to the treatment team."

Correct Answer is B

Explanation

A. While acknowledging the patient's feelings is important, ensuring safety is the priority, and the response should emphasize the ongoing concern for safety.
B. Prioritizing patient safety and care is crucial, especially in situations involving suicidal risks.
C. Encouraging the patient to elaborate further is essential; however, the priority is to maintain the safety precautions.
D. Directing the patient to not participate in their care isn't supportive or therapeutic, especially when safety is a concern.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?

Correct Answer is A

Explanation

A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response?

Correct Answer is B

Explanation

A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? (Select all that apply.)

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem?

A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?