A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?
It doesn’t appear as though you are feeling anxious.
Tell me what has been happening lately.
I think you should see a therapist.
Do you think your anxiety is worse than everyone else’s?
The Correct Answer is B
Choice A reason:
Saying “It doesn’t appear as though you are feeling anxious” is not an appropriate response. This statement invalidates the client’s feelings and can make them feel misunderstood or dismissed. It is important for the nurse to acknowledge the client’s report of anxiety and provide a supportive environment for them to express their concerns.
Choice B reason:
“Tell me what has been happening lately” is the most appropriate response. This open-ended question encourages the client to share more about their experiences and feelings, which can help the nurse understand the underlying causes of the anxiety. It also shows empathy and a willingness to listen, which are crucial in building a therapeutic relationship.
Choice C reason:
“I think you should see a therapist” might be a helpful suggestion, but it is not the best immediate response. While referring the client to a therapist can be part of the long-term management plan, the nurse should first listen to the client’s concerns and provide immediate support. Suggesting therapy right away might make the client feel like their concerns are being brushed off.
Choice D reason:
“Do you think your anxiety is worse than everyone else’s?” is not a helpful response. This question can come across as judgmental and may make the client feel defensive or invalidated. It is important for the nurse to focus on understanding the client’s individual experience rather than comparing it to others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Palpate the client’s pedal pulses
Palpating the client’s pedal pulses assesses the blood flow to the lower extremities but does not provide information about the client’s muscle strength. This action is important for evaluating circulation but is not relevant for determining strength.
Choice B reason: Ask the client how strong she feels today
Asking the client how strong she feels today provides subjective information about the client’s perception of her strength. While this can be useful, it does not offer an objective measure of muscle strength. Objective assessments are more reliable for determining the client’s actual strength.
Choice C reason: Ask the client to touch her finger to her nose
Asking the client to touch her finger to her nose assesses coordination and fine motor skills rather than muscle strength. This test is often used to evaluate neurological function but does not provide information about the strength of the muscles needed for ambulation.
Choice D reason: Ask the client to push her feet against the nurse’s palms
Asking the client to push her feet against the nurse’s palms is an effective way to assess the strength of the lower extremities. This action provides an objective measure of the client’s muscle strength, which is crucial for determining her ability to ambulate safely. This test helps the nurse evaluate whether the client has sufficient strength to stand and walk.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
The statement “Long attention span” is generally not associated with autism spectrum disorder (ASD). Children with ASD often have difficulty maintaining attention on tasks or activities, especially those that do not interest them. They may exhibit hyperfocus on specific interests but typically struggle with sustained attention in other areas.
Choice B reason:
The statement “Delayed language development” is a common characteristic of ASD. Many children with autism experience delays in speech and language skills. They may have difficulty with verbal communication, understanding language, and using language in social contexts. This delay can vary widely among individuals with ASD.
Choice C reason:
The statement “Speaking with direct eye contact” is not typically associated with ASD. Children with autism often avoid direct eye contact and may find it uncomfortable or overwhelming. They might look away or use peripheral vision instead of making direct eye contact during conversations.
Choice D reason:
The statement “Repetitive behavior” is a hallmark of ASD. Children with autism often engage in repetitive behaviors, such as hand-flapping, rocking, or repeating certain actions or phrases. These behaviors can be a way to self-soothe or cope with sensory overload.
Choice E reason:
The statement “Playing with toys repetitively” is also characteristic of ASD. Children with autism may play with toys in a repetitive manner, such as lining them up, spinning them, or focusing on specific parts of the toy rather than using them in imaginative play. This repetitive play is part of the broader pattern of repetitive behaviors seen in ASD.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.