A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?
The nurse is stating disapproval of the statement.
Silence is reflecting the client's sadness.
Silence allows the client to reflect on what was said.
The nurse is respecting the client's loss.
The Correct Answer is C
Choice A rationale: Remaining silent does not necessarily indicate disapproval; it is a therapeutic communication technique to allow the client to express feelings without interruption.
Choice B rationale: While the client may be experiencing sadness, the nurse's silence is not reflecting the client's emotions but rather providing space for the client to express their thoughts and feelings.
Choice C rationale: Silence, in this context, is therapeutic because it allows the client time and space to reflect on and explore their own thoughts and feelings. It promotes self-discovery and expression.
Choice D rationale: Respecting the client's loss is a general principle, but the specific therapeutic use of silence in this situation is to allow the client to process and express their emotions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: The client should avoid all alcohol, not limit consumption to one drink per day.
Choice B rationale: Avoiding all alcohol-containing products while on disulfiram is crucial to prevent a severe reaction called the disulfiram-alcohol reaction.
Choice C rationale: Operating heavy machinery is not a specific concern with disulfiram; avoiding alcohol is the primary focus.
Choice D rationale: Disulfiram can be taken with or without food, and taking it on an empty stomach is not necessary.
Correct Answer is A
Explanation
Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia.
Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication.
Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects.
Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.
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