A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?
"You should try to focus on yourself for a change."
"Why do you feel like things will never work out?"
"Have you been thinking about harming yourself?"
"Maybe an antidepressant will make you feel better."
The Correct Answer is C
Choice A reason:
Telling a client to focus on themselves for a change may come across as dismissive and does not address the underlying feelings of hopelessness. It is important for the nurse to acknowledge the client's feelings and provide support rather than suggesting a shift in focus without understanding the root cause of their distress.
Choice B reason:
Asking the client why they feel like things will never work out can be a useful way to explore their thoughts and feelings. However, it may not be the most immediate concern if the client is experiencing severe hopelessness or suicidal ideation. The nurse should prioritize assessing the client's safety and risk of self-harm.
Choice C reason:
Asking if the client has been thinking about harming themselves is crucial in assessing their safety. Suicidal ideation is a serious concern, and it is important for the nurse to directly address this issue to determine if the client is at risk of self-harm. This response shows that the nurse is taking the client's feelings seriously and is concerned about their well-being.
Choice D reason:
Suggesting an antidepressant might make the client feel better can be helpful in the long term, but it does not address the immediate emotional distress the client is experiencing. Medication can be part of a treatment plan, but the nurse should first ensure the client's immediate safety and provide emotional support.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Responding with "All of your letters come sealed, so that seems unlikely" dismisses the client's feelings and does not address their distress. Clients with delusions need validation of their emotions rather than logical arguments that contradict their beliefs.
Choice B reason:
Telling the client "You know that's not true, because it is against the law for others to read your mail" also dismisses their feelings and may increase their distress. Clients with delusions often hold their beliefs strongly, and simply stating that their belief is false does not help in managing their anxiety or fear.
Choice C reason:
Saying "It must be frightening to think that someone is reading your mail" validates the client's feelings and shows empathy. This response acknowledges the client's fear and opens the door for further discussion about their concerns. It is important to build trust and provide emotional support to clients experiencing delusions.
Choice D reason:
Asking "Why do you think the government wants to read your mail?" can reinforce the delusion by encouraging the client to elaborate on their false beliefs. This approach is not helpful in managing delusions and can lead to further distress.
Correct Answer is D
Explanation
Choice A reason:
Writing a detailed daily activity schedule is not typically indicative of acute mania. Individuals with acute mania often have difficulty focusing and may start many projects but struggle to follow through. A detailed schedule suggests organization, which is not characteristic of mania.
Choice B reason:
Refusing to engage in conversation is not a common sign of acute mania. On the contrary, individuals experiencing mania are more likely to exhibit pressured speech, which is fast, excessive, and difficult to interrupt.
Choice C reason:
Isolating oneself from others is not a typical behavior observed in acute mania. Individuals with mania are more likely to seek out social interactions, although these may be inappropriate or excessive.
Choice D reason:
A lack of sleep is a common symptom of acute mania. Individuals experiencing mania may feel a decreased need for sleep, stay up for long periods, and still not feel tired. This can exacerbate other manic symptoms and is a key indicator of mania.
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