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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Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.

These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.

The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.

A. Postpone the client interview until the next day. B. Document the client's paranoid behavior. C. Attempt to ask the client simple questions. D. Ask another nurse to talk with the client.

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.

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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

Correct Answer is ["A","B","C"]

Explanation

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

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

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