A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

"Come with me to an area where we can talk without interruption."

"Providers usually recommend relaxation exercises for clients who are as upset as you are."

"An antianxiety pill works best for situations like this."

"Most clients with anxiety issues benefit from lying down.".

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Come with me to an area where we can talk without interruption."

Choice A rationale:

The nurse's response of inviting the client to a quieter area for conversation demonstrates therapeutic communication. By offering a private space, the nurse acknowledges the client's distress and creates an environment conducive to open discussion. This response allows the client to express their feelings without the pressure of being observed or interrupted, fostering a sense of safety and trust.

Choice B rationale:

This response suggests recommending relaxation exercises, which might not be appropriate for a client in a heightened state of anxiety. While relaxation techniques can be helpful for managing anxiety, the client's current level of distress requires immediate attention and active engagement rather than advice on future interventions.

Choice C rationale:

Mentioning an antianxiety pill oversimplifies the situation and ignores the importance of therapeutic communication. Medication is not the primary intervention at this moment, and assuming that a pill would be the immediate solution could diminish the client's need to express their feelings and concerns.

Choice D rationale:

Suggesting that most clients with anxiety issues benefit from lying down is an inaccurate generalization. Different individuals have varying coping mechanisms, and the client's pacing and rambling indicate a need for active support and conversation, rather than a one-size-fits-all approach of lying down.

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Correct Answer is C

Explanation

The correct answer is choice C: "I'm hearing that you are concerned that it might turn out that you have cancer."

Choice A rationale:

Dismissing the client's concerns and saying there's no reason to worry is not empathetic. It invalidates the client's feelings and does not address their anxiety.

Choice B rationale:

While discussing concerns with the provider is important, it's not the most therapeutic initial response. The nurse should engage with the client's feelings before suggesting actions.

Choice C rationale:

This is the correct choice. Reflecting the client's concerns back to them shows empathy and encourages them to express their feelings. This approach opens up communication and allows the nurse to provide support.

Choice D rationale:

Asking the client why they think they might have cancer could come across as confrontational and dismissive. The focus should be on understanding their feelings rather than challenging their thoughts.

A. Tardive dyskinesia. B. Acute dystonia. C. Pseudoparkinsonism. D. Neuroleptic malignant syndrome.

Correct Answer is C

Explanation

The correct answer is choice C. Pseudoparkinsonism.

Choice A rationale:

Tardive dyskinesia is a long-term side effect of antipsychotic medications characterized by repetitive, involuntary movements, often around the mouth, such as lip-smacking, tongue protrusion, and chewing movements. It does not typically present with impaired gait and tremors.

Choice B rationale:

Acute dystonia involves sudden, severe muscle contractions, often affecting the neck, face, and back. Symptoms include twisting movements and abnormal postures, but it does not usually cause impaired gait and tremors.

Choice C rationale:

Pseudoparkinsonism is an adverse effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, including bradykinesia (slowness of movement), rigidity, tremors, and postural instability. The impaired gait and uncontrollable tremors observed by the nurse are characteristic signs of pseudoparkinsonism.

Choice D rationale:

Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medications. It presents with symptoms such as high fever, muscle rigidity, altered mental status, and autonomic dysfunction (e.g., unstable blood pressure, sweating). It does not typically present with impaired gait and tremors.

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A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find that I have cancer." Which of the following should be the appropriate response by the nurse?

Correct Answer is C

Explanation

A nurse on a mental health unit observes a diagnosed schizophrenic patient on antipsychotics having an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

Correct Answer is C

Explanation

During a family group therapy session, the nurse overhears the client telling her daughter, "You need to do better in school so I can love you as much as I love your brother." According to Warren, this statement discourages the development of positive self-esteem by hindering which parenting focus?

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A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate that the client is experiencing maladaptive grief?

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?