A nurse is caring for a client:

The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all" In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

she only gets 2 to 3 hours of sleep

She feels that she is "jumpy" after the accident

I feel so sad that I can't seem to feel anything at all"

The client has returned to work at an accounting firm

Answer and Explanation

The Correct Answer is ["A","B","C"]

In the scenario presented, the nurse should prioritize addressing the client's sleep disturbances, heightened startle response, and feelings of sadness and numbness. These symptoms may indicate acute stress reaction or post-traumatic stress disorder, conditions that can occur after experiencing a traumatic event such as a car crash. Immediate interventions could include providing a safe and calm environment, offering support and reassurance, assessing for risk of harm to self or others, and referring to mental health professionals for further evaluation and treatment. It's also important to acknowledge the client's proactive steps, such as joining a grief support group and exercising, which are positive coping strategies. The nurse should collaborate with the client to build on these healthy habits while addressing the more distressing symptoms with appropriate care and referrals.

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Correct Answer is D

Explanation

A. Ignoring nonverbal behavior may overlook important cues that could provide valuable insight into the client's condition and needs.
B. Integrating verbal and nonverbal messages is important, but it may not address the discrepancy or the potential significance of the nonverbal cues.
C. Asking the client's spouse to interpret the discrepancy may not be appropriate or effective, as the spouse may not fully understand the client's nonverbal cues or their significance.
D. Paying close attention and documenting nonverbal messages allows the nurse to gather comprehensive data and potentially explore the observed discrepancy further in subsequent interactions or assessments.

A. Initiate a non-threatening conversation with the client. B. Allow the client to identify the way he interacts. C. Dialog about the ineffectiveness of his interactions. D. Discuss the client's feelings when he responds.

Correct Answer is B

Explanation

A. While initiating a non-threatening conversation with the client may be a goal of therapeutic communication, the main goal of this particular technique is to allow the client to identify his own behaviors by observing the nurse's demonstration.
B. The main goal of this therapeutic technique is to allow the client to observe his own behaviors by seeing them demonstrated by the nurse, which can facilitate insight and self-awareness.
C. Dialoguing about the ineffectiveness of his interactions may occur after the client has identified his behaviors, but it is not the primary goal of this specific technique.
D. Discussing the client's feelings when he responds may be part of the therapeutic process but is not the main goal of this particular technique, which focuses on self-observation and insight.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?