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 C

Explanation

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

A. "You appear to be speaking with someone." B. "Let's talk about the next time this happens." C. "You need to be calm and focus on something else." D. "The voices you are hearing are not real."

Correct Answer is A

Explanation

A. This comment acknowledges the client's behavior without making assumptions or judgments about the content of the hallucinations. It validates the client's experience and opens the door for further discussion if the client wishes to share more about what they are experiencing.
B. This comment does not directly address the client's current experience and may not be as helpful in validating the client's reality.
C. This comment focuses on redirecting the client's attention rather than acknowledging their experience, which may not be as therapeutic in this context.
D. This comment may invalidate the client's experience by directly contradicting their perception of reality. It is important to avoid dismissing or denying the client's experiences without further assessment and understanding.

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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?

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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