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

Spend time sitting in silence with the client.

Involve the client in a daily exercise program.

Ask the client to describe her depression.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Spending time sitting in silence with the client can be a therapeutic intervention for someone who is depressed and experiencing delayed responses. It allows the client to feel a sense of presence and support without the pressure to speak or respond immediately.
This approach can help create a safe and non-judgmental environment for the client to express themselves when they are ready.

Choice B rationale:
Involving the client in a daily exercise program may be a beneficial part of the overall care plan for managing depression, but it does not directly address the client's delayed responses during interactions.

Choice C rationale:
Asking the client to describe her depression may be a useful therapeutic intervention to explore the client's feelings and experiences, but it should be done in a way that respects the client's pace and readiness to discuss her emotions.

Choice D rationale:
Observing for signs of possible psychosis is important for assessing the client's mental health, but delayed responses alone may not necessarily indicate psychosis. It's essential to consider the broader clinical picture and conduct a comprehensive assessment.

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Correct Answer is C

Explanation

Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.

A. Preoccupation. B. Reexperience. C. Somatization. D. Disorganization.

Correct Answer is C

Explanation

Choice A rationale:
Preoccupation typically involves excessive thoughts or worries about a particular topic and may not directly manifest as physical symptoms like numbness and tingling.

Choice B rationale:
Reexperience often refers to the reliving of traumatic events through flashbacks or intrusive memories and is more closely associated with conditions like post-traumatic stress disorder (PTSD).

Choice C rationale:
Somatization refers to the expression of psychological distress through physical symptoms. In this case, the client's numbness and tingling on the right side of the body may be somatic symptoms related to the psychological distress and grief experienced after the spouse's death.

Choice D rationale:
Disorganization is not typically associated with physical symptoms like numbness and tingling. It may relate to cognitive or emotional difficulties but not to these specific physical sensations.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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