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A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

"It sounds like you're having a difficult time."

"Have you talked to your provider about this yet?"

"Everyone has trouble sleeping at times."

"Why do you think you are so anxious?"

Answer and Explanation

The Correct Answer is A

Answer: A. "It sounds like you're having a difficult time."

Rationale:

A) "It sounds like you're having a difficult time":

This response is empathetic and acknowledges the client's distress. By validating the client's feelings, the nurse provides support and opens the door for further discussion about their anxiety and related symptoms. This approach can help the client feel understood and encourage them to share more about their experience.

B) "Have you talked to your provider about this yet?":

While it is important for the client to communicate their symptoms to their provider, this response might come across as dismissive of the client's immediate emotional state. It could be more supportive to first acknowledge the client's current experience before suggesting further actions.

C) "Everyone has trouble sleeping at times":

This response may minimize the client's concerns and fail to address their specific experience. It can come off as invalidating by suggesting that their situation is normal and not warranting further exploration or support.

D) "Why do you think you are so anxious?":

Asking why the client feels anxious might be perceived as interrogative rather than supportive. This approach could put pressure on the client to explain their feelings, which might not be productive if they are struggling to articulate their emotions or causes of anxiety.

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Correct Answer is D

Explanation

Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.

Choice A, placing the client in a private room, does not address the client’s physical needs.

Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.

Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.

A. "If I wake up at night, I go to another room and read for 20 minutes." B. "I eat my evening meal at least 3 hours before I go to bed." C. "I watch the television in my bedroom to help me sleep." D. "I have stopped taking naps in the afternoon."

Correct Answer is C

Explanation

"I watch the television in my bedroom to help me sleep." This technique requires further teaching as watching TV before sleep is a poor sleep hygiene habit. Clients should be advised to keep TVs, mobile phones, and other electronic devices out of the bedroom, as electronic devices can be a source of stimulation and disrupt a sleep routine. Adequate sleep hygiene techniques include going to bed and waking up at the same time every day, avoiding caffeine, nicotine, and alcohol, and engaging in physical activity early in the day. Reading for a few minutes or engaging in some other relaxing activity can reduce difficulty falling back to sleep.

Option A: "If I wake up at night, I go to another room and read for 20 minutes" - This is a good sleep hygiene habit

Option B: "I eat my evening meal at least 3 hours before I go to bed" - This is a good sleep hygiene habit Option D: "I have stopped taking naps in the afternoon" - This is a good sleep hygiene habit Each of the other options helps with good sleep hygiene but C will not help.

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A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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