A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

"It might help you feel better if you talk about it."

“Why are you feeling so down?"

“I just sit here with you for a few minutes then."

"I understand. I've felt like that before, too."

Answer and Explanation

The Correct Answer is C

The appropriate response for the nurse in this situation would be: "I'll just sit here with you for a few minutes then."
This response acknowledges the client's expressed desire not to talk and respects their boundaries. It shows support and presence by offering companionship without pressuring the client to discuss their feelings. The nurse's willingness to sit with the client demonstrates empathy and provides a sense of comfort and reassurance.
The other options are not as appropriate:

1.   "It might help you feel better if you talk about it." This response disregards the client's stated preference not to talk and may create a sense of pressure or intrusiveness. It is important to respect the client's autonomy and readiness to share their feelings.
2.   "Why are you feeling so down?" This response directly asks the client to explain their feelings, which they have already indicated they do not want to discuss. It can be seen as intrusive and may make the client feel uncomfortable or defensive.
3.   "I understand. I've felt like that before, too." While empathy is important, this response brings the focus back to the nurse's own experiences, potentially diverting the attention from the client. It is important for the nurse to remain focused on the client's needs and create a supportive environment for them to express their feelings if they choose to do so.

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Correct Answer is B

Explanation

Determining if the client has thoughts of self-harm: This is the priority action for the nurse in this situation. Assessing the client's risk of self-harm or suicide is crucial to determine the level of immediate intervention required. It helps identify the severity of the crisis and enables the nurse to implement appropriate measures to ensure the client's safety.

In the context of a client with generalized anxiety disorder who is exhibiting signs of distress and seeking to be taken care of, it is essential to assess for suicidal ideation or intent. Clients with mental health disorders, especially when experiencing high levels of stress, may be at an increased risk of self-harm or suicide. Therefore, it is vital for the nurse to prioritize the assessment of the client's safety and risk of self-harm in order to provide appropriate care and interventions.

Incorrect:

A- Asking the client to identify the cause of the crisis: While it is important to gather information about the cause of the crisis to understand the client's situation, it is not the nurse's priority at this moment. Assessing the client's safety and immediate risk of self-harm takes precedence.

C- Identifying if friends or family are available to help: While social support from friends and family can be valuable in managing a crisis, it is not the nurse's priority in this situation. The immediate concern is to assess the client's safety and risk of self-harm.

D-Identifying the client's coping skills: Assessing the client's coping skills is an important aspect of the overall assessment process, but it is not the priority at this moment. The nurse needs to first ensure the client's safety and address any immediate risks.

A. Projection B. Dissociation C. Repression D. Sublimation

Correct Answer is B

Explanation

Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.

A- Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.

C- Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.

D- Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.

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A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission assessment for a cilent who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?

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A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?