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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: "Do you think someone is trying to harm you?" is a leading question and may contribute to the client's paranoid thoughts. It is important to explore the client's concerns without making assumptions.

Choice B rationale: "What makes you think people are stalking you?" is an open-ended question that invites the client to share more about her experiences and thought processes. It allows for a deeper exploration of the client's perceptions.

Choice C rationale: "It sounds like this experience is frightening for you" is a closed statement and may not encourage the client to elaborate on her thoughts. Open-ended questions are more effective in this situation.

Choice D rationale: "I know you are frightened, but no one is stalking you" is a dismissive statement that may invalidate the client's feelings. It is imp

A. Remain calm and use a matter-of-fact approach. B. B Assist the client in developing alternative coping skills. C. Administer an as needed (PRN) sedative to help relieve anxiety. D. Ask the client why she is so anxious.

Correct Answer is A

Explanation

Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.

Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

Correct Answer is B

Explanation

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Correct Answer is A

Explanation

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