When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Involve client in daily exercise program.

Ask the client to describe her depression.

Spend time sitting in silence with client.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is C

A.   Involving the client in a daily exercise program may be beneficial for depression but does not directly address the issue of delayed responses during questioning.
B.   Asking the client to describe her depression may be helpful for assessment purposes but does not address the immediate need of dealing with delayed responses.
C.   Spending time sitting in silence with the client allows the nurse to provide a supportive presence without pressure for immediate responses, which can be helpful for a client experiencing depression-related delays in communication.
D.   Observing for signs of possible psychosis is important but may not be indicated solely based on delayed responses; other symptoms would need to be present to warrant this concern.

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Correct Answer is D

Explanation

A. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C. While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D. Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

A. Ask the client to describe and identify the source of the feelings. B. Provide education about ways to cope with anxiety. C. Assist the client with relaxation techniques in the group. D. Escort the client from the group to reduce stimuli.

Correct Answer is D

Explanation

A. Asking the client to describe and identify feelings is more appropriate for a client with mild to moderate anxiety, not severe anxiety.
B. Providing education is ineffective during severe anxiety because the client is unable to process new information.
C. Relaxation techniques are difficult for a client to use during severe anxiety due to impaired concentration and focus.
D. Reducing environmental stimuli by escorting the client from the group is the best intervention for severe anxiety, as it helps the client regain control and lowers anxiety levels.

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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

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