A client states, "I don't know what to do.
My life is a mess." What is an appropriate response by the nurse?
Place the client on a 72-hour hold immediately.
Remain attentive, but silent.
Leave the room immediately.
Tell the client that everything will be fine.
The Correct Answer is B
Remaining attentive but silent is an appropriate response by the nurse.
This allows the client to express their feelings and concerns without interruption or judgment.
It also shows the client that the nurse is actively listening and interested in what they have to say.
Choice A is not an appropriate response because placing a client on a 72-hour hold should only be done if the client is a danger to themselves or others.
Choice C is not an appropriate response because leaving the room immediately would be unprofessional and could make the client feel abandoned.
Choice D is not an appropriate response because telling the client that everything will be fine may not be true and could give false hope.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Working.
The working phase of the therapeutic relationship is when the nurse and client work together to develop and implement strategies to achieve the client’s goals.
In this case, the goal is to reduce weight, so the nurse and client are working on strategies to achieve that goal.
Choice A is not an answer because the pre-interaction phase occurs before the nurse and client meet and involves the nurse preparing for the first interaction with the client.
Choice B is not an answer because the orientation phase is when the nurse and client get to know each other and establish trust and rapport.
Choice D is not an answer because the termination phase occurs when the therapeutic relationship ends and involves evaluating progress and planning for future care.
Correct Answer is C
Explanation
The nurse’s priority action when an eight-year-old child is eating a hotdog and begins coughing is to promote coughing.
Coughing is the body’s natural way of trying to clear an obstruction from the airway.
Choice A is not the correct answer because beginning the Heimlich maneuver quickly is not the first action that should be taken.
Choice B is not the correct answer because telling the child to put his hands by his neck to signify that he is choking is not the first action that should be taken.
Choice D is not the correct answer because leaving the child alone to find a phone is not the first action that should be taken.
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