A client is agitated and pacing in the hall near the nurses' station and swearing loudly. What response is the best for the registered nurse to provide?
Select one:
Others are being distracted; Please, quiet down and go to your room.
You seem pretty upset. Tell me about it
Please go to your room to get control of yourself.
What’s going on? Be quiet.
The Correct Answer is B
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Denial is a defense mechanism where an individual refuses to accept or acknowledge the existence of a problem or a reality that causes anxiety or distress. In this scenario, the client is denying that their coughing is related to their lung cancer, and instead attributing it to a common cold that everyone is getting. This denial may be a way for the client to avoid facing the reality of their illness and the potential consequences of smoking.
Option b, reaction formation, is a defense mechanism where an individual expresses feelings or behaviors that are the opposite of their true feelings to reduce anxiety.
Option c, sublimation, is a defense mechanism where an individual channels their unacceptable impulses into more acceptable or socially appropriate behaviors.
Option d, suppression, is a defense mechanism where an individual consciously pushes down or avoids their thoughts or feelings. None of these defense mechanisms are being exhibited in the scenario described.
Correct Answer is B
Explanation
Disulfiram is a medication used in the treatment of alcohol addiction. It works by causing unpleasant symptoms, such as nausea and vomiting, when alcohol is consumed. This medication is only effective if the client abstains from alcohol consumption while taking it. If the client consumes alcohol while taking disulfiram, they will experience severe adverse effects, including nausea and vomiting, which can be a sign of a severe reaction. Therefore, it is crucial for the nurse to suspect that the client's distress is likely caused by consuming alcohol while taking disulfiram.
Option a is incorrect because nausea and vomiting are not common side effects of disulfiram.
Option c is incorrect because the question does not provide any information suggesting an allergic reaction.
Option d is incorrect because an overdose of disulfiram would not likely cause nausea and vomiting as severe as those reported by the client.
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