A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

"How long has this been going on?"

"Why do you think you are so anxious?"

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

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

Answer and Explanation

The Correct Answer is D

A. "How long has this been going on?":

While this question is important for gathering more information, it may come across as more investigative or less empathetic at this initial stage of the conversation.

B. "Why do you think you are so anxious?":

While it's important to understand the client's perspective, this response might come across as confrontational or judgmental. It's better to create an open and non-judgmental environment for the client to share their feelings.

C. "Have you talked to your parents about this yet?":

This response assumes that the client has parents to talk to and may not be relevant for all clients. It's also important to establish trust and rapport with the client before asking about their support network.

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

This response is empathetic and validating. It acknowledges the client's feelings without making assumptions or demands, creating a supportive environment for further discussion.

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Correct Answer is C

Explanation

A. The client has begun playing basketball with several other clients during the past month.

Engaging in activities and social interactions can actually be a positive sign, as it suggests involvement and connection with others, which can be protective against suicide.

B. The client identifies with problems expressed by other clients.

Identifying with others' problems may indicate empathy, but it is not necessarily indicative of suicide risk on its own.

C. The client's behavior has become impulsive in the past few weeks.

Explanation: Impulsivity can be a significant risk factor for suicide. A sudden increase in impulsive behavior might indicate that the client is not thinking clearly and is acting without considering the potential consequences. Impulsivity can lead to actions that are harmful or dangerous, including suicidal behaviors.

D. The client states she wants to go home to be with her children and partner.

Expressing a desire to be with loved ones is generally not an indicator of suicide risk. In fact, having a strong support system can be protective against suicidal thoughts.

A. We can call your family in time for them to get here." B. tell your family of your concern so that they can be here C. I will make sure a staff member is in your room at all times." D. I wonder if you are fearful of dying alone."

Correct Answer is D

Explanation

A. "We can call your family in time for them to get here."

While involving the family is important, this response assumes that the client's concern is solely about family being present. The client's statement might have deeper emotional layers, such as fear or regret, that should be addressed.

B. "Tell your family of your concern so that they can be here."

This response puts the responsibility on the client to communicate their concerns to the family. The nurse's role is to provide support and facilitate communication, rather than placing the burden on the client.

C. "I will make sure a staff member is in your room at all times."

While ensuring the client is not alone is important, this response doesn't address the client's emotional concerns or open a dialogue about their feelings. Simply having a staff member present might not address the underlying fear or anxiety the client is experiencing.

D. "I wonder if you are fearful of dying alone."

Explanation: The nurse's response empathizes with the client's feelings and invites a conversation about their emotions. It acknowledges the client's concerns and opens the door for a more in-depth discussion about their fears and feelings regarding dying alone. This approach is patient-centered and encourages the client to express their emotions.

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A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

Nursing Test Bank

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