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?".

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

While wanting to go home to be with loved ones can be a sign of distress, it doesn't necessarily indicate an immediate risk of suicide. Many individuals express a desire to be with family when feeling down, and this statement alone is not a definitive indicator of suicide risk.

Choice B rationale:

Engaging in social activities like playing basketball with others is generally a positive sign, as it indicates some level of interaction and engagement. This choice is less likely to indicate an immediate suicide risk.

Choice C rationale:

The client demonstrating increased impulsive behaviors is a concerning sign. Rapid and impulsive actions can potentially lead to self-harm or dangerous situations. Increased impulsivity can indicate a lack of consideration for consequences, which may elevate the risk of suicidal behaviors.

Choice D rationale:

Identifying with problems expressed by other clients is not a specific indicator of suicide risk. While it may suggest empathy and shared experiences, it doesn't directly address the immediate risk factors related to the client's bipolar disorder.

A. Aggressive behavior. B. Attention-seeking conduct. C. Mild fidgeting. D. Mild difficulty problem-solving.

Correct Answer is A

Explanation

Choice A rationale:

(Correct) Severe anxiety can lead to a fight-or-flight response, which might manifest as aggressive behavior. The individual might feel threatened and react defensively, potentially displaying aggressive actions to protect themselves.

Choice B rationale:

Attention-seeking conduct is less likely to be a primary manifestation of severe anxiety. While individuals with anxiety might seek reassurance or attention, the level of anxiety described here is more likely to evoke a defensive response rather than attention-seeking behavior.

Choice C rationale:

Mild fidgeting can be a manifestation of anxiety, but in the context of severe anxiety, the physical symptoms are often more pronounced, including restlessness, trembling, and muscle tension.

Choice D rationale:

Mild difficulty problem-solving is less likely to be a prominent manifestation of severe anxiety. Severe anxiety tends to affect the individual's ability to function and cope, leading to more intense and immediate reactions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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