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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Correct Answer is D
Explanation
This response acknowledges the client's feelings and respects their desire for space and silence. By offering to sit with the client, the nurse provides a comforting presence without pressuring the client to talk or share their emotions. It shows understanding and support for the client's current emotional state.
The other options may not be as helpful in this situation:
A- "Why are you feeling so down?" can be seen as intrusive and may make the client feel defensive or overwhelmed. It's important to respect the client's boundaries and not push them to explain their feelings if they are not ready.
B- "It might help you feel better if you talk about it." While talking about feelings can be beneficial for some individuals, it should be done on the client's terms. Pressuring the client to talk about their emotions may create additional distress.
C- "I understand. I've felt like that before, too." While sharing personal experiences can be a way to establish rapport, it should be done cautiously and with consideration for the client's unique situation. In this case, the focus should be on the client's needs rather than the nurse's experiences.
Correct Answer is C
Explanation
Remaining with the client provides them with a sense of security, reassurance, and support. It shows the client that they are not alone and that the nurse is there to provide assistance and care. By being present and offering a calming presence, the nurse can help the client feel more at ease and gradually reduce their anxiety.
It's important to note that the other options are not the most appropriate actions in this situation:
A- Having the client join a therapy group may be overwhelming and may not be suitable during the acute phase of panic-level anxiety.
B- Suggesting that the client rest in bed may not address their immediate anxiety and may not be feasible if the client is experiencing intense anxiety symptoms.
D- Medicating the client with a sedative should be done based on a healthcare provider's order and assessment of the client's condition. It is not the initial therapeutic intervention and should only be considered if other non-medication interventions are ineffective or if the client's anxiety becomes severe and unmanageable.
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