A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

stop the client in the hall and tell them that they must pace in the day room instead.

keep hands in pockets so as not to appear threatening.

speak softly and calmly,

offer the client a cup of coffee.

Answer and Explanation

The Correct Answer is C

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

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Correct Answer is ["A","B","D"]

Explanation

a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.

b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.

c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.

d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.

e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.

A. "Can you order the specific events that led to your admission?" B. "Do you know why you are here?" C. "Are you feeling depressed or anxious?" D. "Yes, I see. Go on."

Correct Answer is D

Explanation

a. "Can you order the specific events that led to your admission?" This statement directs the client to provide specific information and is more focused than a general lead. It does not encourage a broad response.
b. "Do you know why you are here?" This question is somewhat open-ended but still directs the client's response toward understanding their admission.
c. "Are you feeling depressed or anxious?" This question is specific and closed-ended, prompting a choice between two options rather than encouraging the client to freely elaborate.
d. "Yes, I see. Go on." This is correct because it encourages the client to continue speaking without directing the topic, which is the essence of a general lead.

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A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

Correct Answer is D

Explanation

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

The nurse recognizes that a function of the Mental Status Exam is:

Which of the following would be the best nursing action for a client who is having a panic attack?

Which major health complication is associated with a client diagnosed with anorexia nervosa, does the nurse assess as a priority?

If a client demonstrates transference towards the nurse, how should the nurse respond?

A client with schizophrenia is receiving teaching from the nurse about their prescribed medication, Chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?