A nurse is taking care of an adult client who 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?".
"It sounds like you're having a difficult time.".
"Have you talked to your parents about this yet?".
"Why do you think you are so anxious?".
The Correct Answer is B
The correct answer is choice B. "It sounds like you're having a difficult time."
Choice A rationale:
"How long has this been going on?" This question focuses on the duration of the client's symptoms, which might not be the most appropriate response at this point. The client's immediate emotional state and distress should be acknowledged before delving into the duration of the issue.
Choice B rationale:
"It sounds like you're having a difficult time." This response demonstrates empathy and understanding towards the client's emotional state. It acknowledges the client's feelings without making assumptions or probing for specific details. It provides a supportive environment for the client to open up further.
Choice C rationale:
"Have you talked to your parents about this yet?" This question assumes that the client's parents are a source of support and that the client has not yet spoken to them about their feelings. It also directs the conversation towards external parties instead of focusing on the client's immediate emotions.
Choice D rationale:
"Why do you think you are so anxious?" This question might come across as confrontational or demanding, potentially making the client defensive. It could hinder open communication and create a barrier between the nurse and the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D:
Choice A reason: “If a dose is missed, double the next dose of medication.” This statement is incorrect. Doubling up on a dose can lead to an overdose and serious side effects. Patients are advised to take the missed dose as soon as they remember unless it’s almost time for the next dose.
Choice B reason: “This medication may increase your blood pressure.” Alprazolam is known to have a sedative effect, which can lower blood pressure rather than increase it. Therefore, this statement is not typically accurate.
Choice C reason: “Do not eat aged cheeses while taking this medication.” This dietary restriction is associated with monoamine oxidase inhibitors (MAOIs), which are a different class of medications used to treat depression. Alprazolam does not interact with tyramine-rich foods like aged cheeses, so this statement is not applicable.
Choice D reason: “Use a dependable form of contraception while taking this medication.” Alprazolam falls under FDA Pregnancy Category D, which means there is positive evidence of human fetal risk, but the potential benefits may warrant use in pregnant women despite the risks. Therefore, it is important to use reliable contraception to prevent pregnancy while taking this medication.
Correct Answer is B
Explanation
The correct answer is choice B. Erotomanic.
Choice A rationale:
Persecution. Persecutory delusions involve the belief that one is being targeted, harmed, or conspired against by others. This choice is not applicable in this scenario because the client is not expressing fear or belief that they are being persecuted.
Choice B rationale:
Erotomanic. Erotomanic delusions involve the false belief that someone, often of higher social status, is in love with the individual. In this case, the client's statement about being engaged to the Prince of England suggests an erotomanic delusion. The client is holding a grandiose belief that they are romantically involved with someone of prominence.
Choice C rationale:
Somatic. Somatic delusions involve the belief that there is something physically wrong with the individual's body. These delusions often manifest as the belief in having an illness or defect that is not actually present. The client's statement does not revolve around physical health or bodily concerns, making somatic delusion an unlikely option.
Choice D rationale:
Control. Control delusions involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This choice is not applicable in this scenario, as the client's statement does not indicate any perceived loss of control over their thoughts or actions.
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