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 D

Explanation

Choice D rationale:

Setting limits on the client's behavior and maintaining consistency is essential when dealing with a client experiencing a manic episode. Manic episodes are characterized by impulsive and often disruptive behaviors. By setting clear limits, the nurse establishes boundaries that help manage the disruptive behavior and maintain a safe and therapeutic environment. Consistency in approach is vital to avoid confusion and to provide the client with a sense of stability during a time when their judgment and impulse control might be impaired.

Choice A rationale:

Warning the client that further disruptions will result in seclusion might escalate the situation and potentially worsen the client's agitation. It's crucial to use non-confrontational approaches when dealing with clients experiencing manic episodes to prevent increased agitation and aggression.

Choice B rationale:

Ignoring the client's behavior is not a suitable approach, as it could lead to a deterioration of the situation and potentially compromise the safety and well-being of both the client and others on the unit. It's important to address disruptive behavior promptly and appropriately.

Choice C rationale:

Asking the client to recommend consequences for her disruptive behavior might not be effective during a manic episode. Clients in a manic state might not have a realistic or rational perspective on their behavior, and involving them in determining consequences could lead to unreasonable outcomes.

A. "You should try to see your partner's point of view before your own.” B. "Relationship difficulties are stressful and require effort to resolve.” C. "We could develop a plan for how to talk about this with your partner.” D. "Tell me more about the concerns that you have regarding your marriage.”

Correct Answer is A

Explanation

Choice A rationale:

Similar to the explanation in , this statement requires intervention. It reflects a judgmental and prescriptive approach, which is not conducive to a therapeutic conversation. It implies that the nurse knows what the client should do, undermining the client's autonomy and self-discovery process.

Choice B rationale:

Recognizing that relationship difficulties are stressful and require effort to resolve is a valid and supportive statement. It acknowledges the challenges the client is facing and does not impose a specific solution.

Choice C rationale:

Suggesting the development of a communication plan is a proactive and therapeutic response. It empowers the client to work collaboratively toward improving their marital situation.

Choice D rationale:

Encouraging the client to share more about their concerns promotes open communication and allows the nurse to better understand the client's perspective. This response is client-centered and supportive.

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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 caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Correct Answer is A

Explanation

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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 assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

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A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

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