A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he 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?
"Most clients with anxiety issues benefit from lying down."
"An antianxiety pill works best for situations like this."
"Providers usually recommend relaxation exercises for clients who are as upset as you are."
"Come with me to an area where we can talk without interruption."
The Correct Answer is D
This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.
A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.
B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.
C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.
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Related Questions
Correct Answer is C
Explanation
Obtaining informed consent is a crucial step before administering electroconvulsive therapy (ECT). Informed consent ensures that the client is fully informed about the procedure, its potential risks and benefits, and any alternative treatments available. It allows the client to make an autonomous decision regarding their treatment.
The other responses are not accurate:
A- "ECT is an effective treatment for personality disorders." While ECT may be used in certain cases of severe mental illness, it is not primarily indicated for personality disorders.
B- "It is a myth that clients experience seizures during ECT." Seizures are a common and expected effect of ECT. ECT involves the induction of controlled seizures under anesthesia.
D- "Should monitor the client closely for hypotension following ECT." While monitoring the client for various physiological changes is important, hypotension is not a primary concern following ECT. The nurse would typically monitor for potential adverse effects such as confusion, memory loss, headache, and muscle soreness.
Correct Answer is A
Explanation
In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.
Incorrect:
B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.
C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.
D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.
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