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

“Why are you feeling so down?"

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

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

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

Answer and Explanation

The Correct Answer is B

A. "Why are you feeling so down?"

This response could come across as confrontational or invasive, potentially making the client feel uncomfortable. The client has already expressed their desire not to talk at the moment, so pushing for an explanation may not be well-received.

B. "I’ll just sit here with you for a few minutes then."

Explanation:

This response shows empathy and support without pushing the client to talk or sharing personal experiences. It respects the client's desire for space and acknowledges their emotions without being intrusive. It provides a calming and non-intrusive presence, giving the client the option to open up if and when they are ready.

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

While sharing personal experiences can sometimes be helpful, in this context, it might inadvertently shift the focus from the client's emotions to the nurse's experiences. It's important to keep the focus on the client and their feelings.

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

Suggesting that talking might help is well-intentioned, but it might pressure the client into discussing their feelings when they have clearly stated their preference not to at that moment. The client's autonomy and comfort should be respected.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Hyperactivity: While some individuals with eating disorders may engage in excessive physical activity as a form of compensatory behavior, hyperactivity is not a consistent and universal manifestation.

B. Amenorrhea: Adolescents with eating disorders, particularly anorexia nervosa, often experience amenorrhea (absence of menstrual periods) due to hormonal imbalances and low body weight.

C. Verbalized desire to gain weight: Individuals with eating disorders, especially anorexia nervosa, often express a strong desire to lose weight rather than gain weight, which contributes to their restrictive eating habits.

D. Altered body image: Eating disorders are often associated with distorted body image, where individuals perceive themselves as overweight or larger than they actually are, even if they are underweight.

E. Bradycardia: Severe malnutrition, as seen in eating disorders like anorexia nervosa, can lead to bradycardia (slow heart rate) as the body conserves energy in response to the low caloric intake.

A. Plan the client's schedule to allow time for rituals. B. Confront the client about the senseless nature of the repetitive behaviors. C. isolate the client for a period of time. D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Correct Answer is A

Explanation

A. Plan the client's schedule to allow time for rituals.

Explanation:

For individuals with obsessive-compulsive disorder (OCD), engaging in rituals or repetitive behaviors can be a way to manage anxiety. Allowing time for these rituals within the client's schedule, while gently working towards reducing their impact, is a part of a gradual therapeutic approach known as Exposure and Response Prevention (ERP). ERP aims to help the client gradually face their anxiety triggers while refraining from engaging in compulsions.

Why the other choices are incorrect:

B. Confront the client about the senseless nature of the repetitive behaviors.

Confrontation can increase the client's anxiety and resistance to treatment. Instead, the nurse should approach the client with understanding and gradually work on strategies to reduce the compulsive behaviors.

C. Isolate the client for a period of time.

Isolating the client is not a therapeutic approach for managing OCD. It can lead to increased distress and negatively impact their mental health. Inclusion and support are more effective strategies.

D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Setting strict limits may escalate the client's anxiety and could be counterproductive. It's important to work collaboratively with the client and apply evidence-based approaches like ERP to manage their symptoms effectively.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D","E"]

Explanation

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

Correct Answer is A

Explanation

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

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