A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?
"You may think you are fat, but you look thin to me."
"There are consequences for not eating."
"Explain how you feel when it is time to eat."
"You must eat or you will become very sick."
The Correct Answer is C
Choice A rationale: "You may think you are fat, but you look thin to me" is dismissive and may invalidate the client's feelings. It is essential to explore the client's emotions rather than providing a judgmental response.
Choice B rationale: "There are consequences for not eating" is confrontational and may increase the client's anxiety. A more therapeutic approach involves exploring the client's feelings and concerns about eating.
Choice C rationale: "Explain how you feel when it is time to eat" is an open-ended and non-judgmental response. It encourages the client to express her emotions, providing valuable information for further assessment and care planning.
Choice D rationale: "You must eat or you will become very sick" is directive and may increase resistance. It is essential to explore the client's feelings and collaborate on a plan rather than issuing directives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.
Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.
Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.
Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.
Correct Answer is C
Explanation
Choice A rationale: A body mass index (BMI) of 21 is within the normal range and does not require immediate notification to the healthcare provider.
Choice B rationale: A blood pressure of 110/70 mm Hg is within the normal range for an adolescent and does not require immediate notification.
Choice C rationale: A potassium level of 2.9 mEq/dL (2.9 mmol/L) is below the normal range (hypokalemia) and requires notification to the healthcare provider due to the potential for adverse effects on cardiac and neuromuscular function.
Choice D rationale: A WBC of 10,000/mm3 (10 x 109/L) falls within the normal range and does not require immediate notification.
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