A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

"The unit rules state that you may not remain in bed."

"You can remain in bed until you feel well enough to join the group."

"I will assist you in getting out of bed and getting dressed."

"If you don't participate in your care, you will not get better."

Answer and Explanation

The Correct Answer is C

Choice A reason:
This choice represents an authoritative approach, which may not be effective with a depressed client who is refusing therapy and ADLs. It does not offer support or understanding of the client's condition and may exacerbate feelings of helplessness or resistance to care.

Choice B reason:
While this statement offers a degree of autonomy to the client, it lacks the active encouragement and assistance that might be necessary to motivate a client who is depressed. It does not address the importance of participating in therapy or ADLs for the client's recovery.

Choice C reason:
This is the most therapeutic choice as it offers both support and a gentle nudge towards participation. It acknowledges the client's current state and provides a clear, immediate, and supportive next step. This approach can help reduce the client's feelings of being overwhelmed and can foster a sense of collaboration between the nurse and the client.

Choice D reason:
This statement, although factual, may come across as confrontational and could potentially discourage the client further. It does not provide the supportive framework that is crucial for engaging a client who is struggling with depression.

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Correct Answer is C

Explanation

Choice A reason:
Escorting the client to the common area is not the priority action. While being around others can sometimes be comforting, during a panic attack, the client may feel overwhelmed and exposed, which could exacerbate the situation.

Choice B reason:
Contacting security for possible restraints should be a last resort and is not the priority action. Restraints can increase anxiety and fear, potentially escalating the panic attack. The use of restraints is only considered when the client is at risk of harming themselves or others and all other interventions have failed.

Choice C reason:
Staying with the client is the priority action. During a panic attack, the client needs reassurance and a sense of safety. The nurse's presence can provide comfort. The nurse should remain calm, use a quiet voice, and avoid making any sudden movements. Implementing relaxation techniques and promoting a calming environment are also beneficial.

Choice D reason:
Staying away from the client is not the priority action. Leaving the client alone can increase feelings of isolation and fear. The nurse should provide continuous observation and support during the panic attack.

A. The client is experiencing withdrawal symptoms. B. The client is experiencing hallucinations. C. The client is at risk for traumatic re-experiencing. D. The client is at risk for self-harm or harm to others.

Correct Answer is D

Explanation

Choice A reason:
The client experiencing withdrawal symptoms should be monitored, as these symptoms can range from mild to severe. Withdrawal symptoms may include fatigue, depression, and anxiety, which are significant but generally not life-threatening. The nurse should provide supportive care and monitor the client's vital signs and emotional state.

Choice B reason:
If the client is experiencing hallucinations, this indicates a more severe level of withdrawal and possibly the presence of a stimulant-induced psychotic disorder. While hallucinations can be distressing and require intervention, they are not the highest priority when compared to the risk of self-harm or harm to others.

Choice C reason:
The risk for traumatic re-experiencing, or flashbacks, is a concern during withdrawal, particularly if the client has a history of trauma. These experiences can be highly distressing and may lead to further psychological distress. However, the immediate physical safety of the client and others takes precedence.

Choice D reason:
The risk of self-harm or harm to others is the most critical safety concern and must be prioritized. Clients withdrawing from stimulants may exhibit increased agitation, aggression, or impulsivity, which can lead to dangerous behaviors. The nurse must take immediate action to ensure a safe environment, which may include close supervision, the use of restraints, or rapid pharmacological intervention.

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A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

Correct Answer is C

Explanation

A nurse is caring for a client who is withdrawing from a stimulant. Which of the following should be prioritized for safety in a client with stimulant withdrawal?

Correct Answer is D

Explanation

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