The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?
Walt for the client to respond.
Ask if the client heard the question.
Ask a different question.
Return at a later time to talk.
The Correct Answer is A
Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.
Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.
Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.
Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.
Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.
Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.
Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.
Correct Answer is A
Explanation
Choice A rationale: Abrupt discontinuation of alprazolam, a benzodiazepine used to treat anxiety disorders, can lead to withdrawal symptoms, including rebound anxiety,
insomnia, and potentially seizures. The statement reflects an understanding of the importance of gradual tapering and not abruptly stopping the medication. Choice B rationale: Reporting side effects such as dizziness, lightheadedness, or sedation is important, but the key focus for long-term benzodiazepine use is the need to avoid abrupt discontinuation.
Choice C rationale: While attending therapy sessions is beneficial for managing anxiety, the question is specifically addressing the self-care goal related to medication use. Choice D rationale: Reporting any decrease in anxiety using a 10-point scale is relevant but not as crucial as emphasizing the avoidance of abrupt discontinuation.
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