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?

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.

The correct answer is choice D.

Choice A rationale:

Encouraging the family to take the client out of the facility for short periods of time may not be appropriate at this point. Abrupt changes in behavior, like sudden cheerfulness, might be a warning sign for potential suicide risk in individuals with depression. Allowing the client to leave the facility could increase the risk of harm.

Choice B rationale:

Rewarding the client for the change in behavior might inadvertently reinforce the idea that acting cheerful is desirable. This could hinder the client's progress and therapeutic understanding of their condition.

Choice C rationale:

Asking the client why her behavior has changed is a thoughtful and reasonable approach, but it might not address the potential underlying issues adequately. Depression can still be present, and sudden shifts in mood should be monitored closely.

Choice D rationale:

Monitoring the client's whereabouts at all times is the appropriate action. Sudden improvements in a depressed client's demeanor could indicate that they have made a decision to end their life. Monitoring ensures their safety and enables prompt intervention if needed.