A nurse is collecting data from a client who states, "I am so worried about everything, and I can't seem to sit still, even when I eat." Which of the following responses should the nurse make?

"I don't understand why you're so upset."

"Don't worry. You'll feel better soon."

"Let's discuss what is bothering you."

"You need to eat to maintain your strength."

Answer and Explanation

The Correct Answer is C

A.   This response may come across as dismissive or lacking empathy. It does not acknowledge the client's feelings or address the underlying concerns contributing to their anxiety. It's important for the nurse to validate the client's emotions and provide reassurance rather than expressing confusion or disbelief.
B.   While this response aims to provide reassurance, it may oversimplify the client's feelings and situation. Anxiety is complex, and telling someone not to worry might not be effective in alleviating their distress. It's crucial to engage the client in a more meaningful conversation about their concerns and offer support tailored to their needs.
C.   This response demonstrates active listening and therapeutic communication. It encourages the client to express their worries and feelings, which can help them feel understood and supported. By discussing what is bothering them, the nurse can gather important information about the client's concerns and begin to address them effectively.
D.   While nutrition is important, this response may come across as directive and could potentially minimize the client's emotional distress. It does not acknowledge the client's anxiety or provide support for their current feelings of restlessness and worry. The nurse should prioritize addressing the client's emotional needs and anxiety before focusing on physical aspects like nutrition.

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Correct Answer is A

Explanation

A. Verbal de-escalation involves using calm, non-confrontational communication techniques to help calm the client. This can include speaking softly, using non-threatening body language, and actively listening to the client's concerns. It is the first-line intervention for managing escalating behavior because it aims to reduce agitation without the use of physical or chemical restraints.
B. Haloperidol is an antipsychotic medication that may be prescribed for acute agitation and aggression in some situations. However, obtaining a prescription requires provider authorization and should not be the first intervention unless the client's agitation poses an immediate threat to safety and verbal de- escalation has been ineffective. It is typically used when other interventions have not successfully managed agitation.

C. Physical restraints should only be used as a last resort and in accordance with institutional policies and legal guidelines. Restraints are intended to prevent harm to the client or others when all other methods of de-escalation have failed and there is an imminent risk of harm. Placing a client in restraints without attempting verbal de-escalation first can escalate the situation further.
D. Seclusion is also a restrictive intervention that should be used judiciously and only when necessary to protect the client or others from harm. It involves placing the client in a designated, secure area where they can be monitored closely. Similar to physical restraints, seclusion should be considered only after attempts at verbal de-escalation have been unsuccessful and there is a clear risk of harm.

A. Acknowledge an inability to control drinking. B. Agree to a prescription for an alcohol use deterrent. C. Form a close support network. D. Incorporate a form of spirituality into daily life.

Correct Answer is A

Explanation

A. This is a crucial first step in recovery. It involves recognizing and accepting that one has lost control over their drinking and that alcohol use is causing negative consequences in their life. Without acknowledging this lack of control, individuals may not be motivated to seek or engage in treatment.
B. While medications such as disulfiram (Antabuse) or naltrexone (Revia) can be part of a comprehensive treatment plan for alcohol use disorder, agreeing to a prescription for an alcohol use deterrent is not typically the first step in recovery. It usually follows assessment, acknowledgment of the problem, and development of a treatment plan in collaboration with healthcare providers.
C. Building a strong support network is indeed crucial for long-term recovery. This network may include family, friends, peers in recovery, and support groups like Alcoholics Anonymous (AA). However, forming this support network is often a step that occurs as part of ongoing treatment and recovery efforts rather than the very first step.

D. Incorporate a form of spirituality into daily life: Spirituality or a sense of purpose can be a significant component of recovery for some individuals, providing strength and motivation. However, it is not universally considered the first step in recovery. Spirituality may be explored and integrated into the recovery journey as individuals progress in treatment and self-discovery.

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A nurse is collecting data from a client who states, "I am so worried about everything, and I can't seem to sit still, even when I eat." Which of the following responses should the nurse make?

Nursing Test Bank

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Correct Answer is A

Explanation

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