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."

Answer and Explanation

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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Correct Answer is D

Explanation

Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.

A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.

B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.

C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.

A. Recognizing the warning signs of suicide B. Identifying individuals who are at higher risk for attempting suicide C. Performing life-saving measures following a suicide attempt D. Providing support for family and friends following a suicide

Correct Answer is C

Explanation

Secondary interventions are aimed at reducing the harm or preventing further complications in individuals who have already engaged in suicidal behavior. In this case, performing life-saving measures after a suicide attempt, such as cardiopulmonary resuscitation (CPR) or administering first aid, falls under the category of secondary intervention.

The other options are examples of primary and tertiary interventions:

A- Recognizing the warning signs of suicide: This is an example of primary intervention, which focuses on preventing suicidal behavior before it occurs by raising awareness, promoting mental health, and identifying risk factors and warning signs.

B- Identifying individuals who are at higher risk for attempting suicide: This is also an example of primary intervention, as it involves assessing and identifying individuals who may be at greater risk for suicidal behavior and implementing preventive measures.

D- Providing support for family and friends following a suicide: This is an example of tertiary intervention, which aims to provide support and care to those who have been affected by a suicide, including family and friends. Tertiary interventions focus on postvention, addressing the aftermath and providing support for survivors.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?

Correct Answer is C

Explanation

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