After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

"We will have to talk about this later."

"what happened that got you so upset?"

"You really scared me. I'm glad you are okay."

"Your behavior is unacceptable and will not be tolerated

Answer and Explanation

The Correct Answer is B

When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse, it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. By asking, "What happened that got you so upset?", the nurse is inviting the client to express their feelings and share what triggered their anger. This can help the nurse understand the client's perspective, provide appropriate support, and potentially de-escalate any remaining tension or frustration.

The other options are inappropriate because:

A- "We will have to talk about this later." This response may make the client feel dismissed or that their feelings are not being heard or understood.

C- "You really scared me. I'm glad you are okay." While this response acknowledges the client's emotional state, it centers the focus on the nurse's feelings rather than exploring the client's perspective or emotions.

D- "Your behavior is unacceptable and will not be tolerated." This response is confrontational and judgmental, which can escalate the situation and potentially trigger further defensive reactions from the client.

Overall, a non-judgmental and empathetic approach that focuses on understanding the client's feelings and experiences is more likely to foster open communication and provide the client with a safe space to express themselves.

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Correct Answer is B

Explanation

Explanation: The priority question the nurse should ask the client during the initial assessment is whether they feel safe in their home (Option B). This question is essential because it addresses the client's safety and well-being, particularly regarding the possibility of domestic violence or intimate partner violence.

Assessing for safety is a critical component of the initial assessment, especially for female clients, as they may be at higher risk for experiencing domestic violence or abuse. By asking about the client's safety in their home, the nurse can identify potential issues related to violence or unsafe living conditions and take appropriate actions to ensure the client's safety.

Options A, C, and D are also important assessment questions, but they are not the priority in this scenario:

A. "Do you have enough money to pay for your care today?" - This is an important question regarding the client's financial situation and ability to access healthcare. However, safety and well-being take precedence over financial concerns in the initial assessment.

C. "Do you take illegal street drugs?" - This question is crucial for assessing the client's substance use and potential risk factors related to drug use. However, the safety question (Option B) is more immediate and directly addresses the client's well-being.

D. "Do you obtain regular medical care?" - This question is vital for assessing the client's healthcare needs and access to healthcare services. However, the safety question (Option B) should be addressed first to ensure the client's immediate safety and well-being.

A. I’m mentally healthy, I can solve my own problems." B. "What can I do? My spouse abandoned me C. I can't understand why this happened to me." D. I will find a support group to help me through this."

Correct Answer is D

Explanation

The statement, "I will find a support group to help me through this," indicates that the client's coping skills are adequate. Seeking support from others who have experienced a similar loss can be an effective way to cope with feelings of loneliness and vulnerability after the death of a spouse. Support groups provide a safe and understanding environment where individuals can share their experiences, feelings, and struggles, and receive emotional support from others who can relate to their situation.

Option A suggests an overconfidence in coping skills and may not fully acknowledge the need for external support during a challenging time.

Option B indicates a sense of feeling abandoned, which could be a sign of struggling coping skills.

Option C suggests confusion and difficulty accepting the loss, which may indicate inadequate coping skills at the moment.

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After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse working in an outpatient clinic is performing an intake assessment for a female client. Which priority question will the nurse ask the client as part of the initial assessment?

Correct Answer is B

Explanation

A young client tells the nurse that the client's spouse died 3 months ago, and the client is feeling alone and vulnerable. Which statement indicates that the client's coping skills are adequate?

Correct Answer is D

Explanation

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

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The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?