A nurse is caring for an adolescent client who has anorexia nervosa. The client asks the nurse, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?
"You should ask your provider that question."
"I wouldn't worry about any permanent damage you might have caused right now."
"Why do you feel like you have damaged your body?"
"You're afraid you have caused physical injury to yourself?"
The Correct Answer is D
Choice A reason: Referring the client to the provider dismisses the client’s immediate concern and does not foster therapeutic communication. While providers can give medical details, the nurse’s role is to explore feelings and provide support. This response blocks communication.
Choice B reason: Telling the client not to worry minimizes their concern and invalidates their feelings. Clients with anorexia nervosa often have significant anxiety about their health and body image. This response is non-therapeutic and does not encourage further discussion.
Choice C reason: Asking “Why” questions can make the client feel defensive and pressured to justify their feelings. Therapeutic communication avoids “Why” phrasing because it can hinder open dialogue.
Choice D reason: Reflecting the client’s concern by restating it in a supportive way acknowledges their fear and invites them to elaborate. This therapeutic response validates the client’s feelings and opens the door for further discussion about their health and emotional state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Clients admitted involuntarily still retain the right to refuse medications unless a court order or emergency situation overrides this right. This statement is incorrect.
Choice B reason: Involuntary admission does not automatically mean a client is incompetent. Competency must be legally determined by a court, not assumed based on admission status.
Choice C reason: Restraints cannot be prescribed on an as-needed basis. They require a specific, time-limited order and must be used only when absolutely necessary to protect the client or others.
Choice D reason: Providers have a duty to warn identifiable individuals if a client makes a credible threat of serious harm. This is a legal and ethical responsibility to protect others from danger, making this the correct statement.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Aphasia, or difficulty with language, can occur in delirium due to acute disruption of cognitive processing. Clients may suddenly struggle to find words, understand speech, or communicate effectively. This is consistent with delirium’s hallmark of acute cognitive disturbance.
Choice B reason: Hallucinations are common in delirium, especially visual hallucinations. They result from acute brain dysfunction and fluctuating consciousness. Hallucinations are a key differentiating feature from dementia, which progresses gradually and is less likely to cause vivid perceptual disturbances in the early stages.
Choice C reason: Akathisia is a movement disorder characterized by inner restlessness and the inability to stay still, often caused by antipsychotic medications. While it may coexist in psychiatric clients, it is not a defining feature of delirium. Therefore, it is not an indicator of delirium.
Choice D reason: Change in level of consciousness is a hallmark of delirium. Clients may fluctuate between hyperalertness and lethargy, often within hours. This acute alteration distinguishes delirium from chronic cognitive disorders such as dementia.
Choice E reason: Decreased attention span is a core diagnostic feature of delirium. Clients are unable to focus, sustain, or shift attention appropriately. This impairment is often the earliest sign noticed by caregivers and clinicians.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.