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 D
Explanation
This client is experiencing auditory hallucinations and may be at risk for self-harm or suicide. The nurse should prioritize visiting this client first to assess their safety and provide appropriate interventions.
Option a. A client who recently burned her arm by accident while using a hot iron at home may require wound care and education on safety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option b. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview may benefit from interventions to manage anxiety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option c. A client who requests that her antipsychotic medication be changed due to some new adverse effects may require medication adjustment and monitoring for side effects, but this situation is not as urgent as the client experiencing auditory hallucinations.
Correct Answer is C
Explanation
This statement shows that the client is not accepting the reality of their prognosis and is dismissing the doctor's professional opinion. Denial is a common stage in the grief process where individuals may refuse to believe or accept a difficult reality, often as a coping mechanism to avoid the pain and sadness of the situation. Options a, b, d, and e do not indicate denial and instead may suggest fatigue, acceptance, physical weakness, and anger or frustration, respectively.
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