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 D
Explanation
Inform the client that driving would be dangerous.
Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and sudden attacks of sleep.
As a result, it can be dangerous for individuals with narcolepsy to engage in activities that require sustained attention and alertness, such as driving.
The nurse’s priority intervention would be to inform the client of this risk and advise them to avoid driving.
Choice A is not an answer because while avoiding caffeine after 6 pm may help improve sleep quality, it is not the priority intervention for a client with narcolepsy.
Choice B is not an answer because drinking two cups of regular coffee may worsen the symptoms of narcolepsy and is not a recommended intervention.
Choice C is not an answer because while participating in normal activities may be beneficial for overall health and well-being, it is not the priority intervention for a client with narcolepsy.
Correct Answer is C
Explanation
The priority responsibility of the nurse is to call for a Cambodian interpreter.
This ensures that the mother’s needs and concerns are accurately communicated and understood.
It also helps to prevent any misunderstandings or miscommunications that could occur if the daughter were to interpret.
Choice A is not an appropriate response because calling the chaplain for support may not address the language barrier.
Choice B is not an appropriate response because allowing unlicensed assistive personnel to interpret could result in inaccurate or incomplete information being conveyed.
Choice D is not an appropriate response because continuing to work with the daughter for interpretation could result in misunderstandings or miscommunications.
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