A patient who is experiencing moderate anxiety says, "l feel undone." An appropriate response for the registered nurse who needs clarification would be:
Select one:
I’m not sure I understand. Please give me an example...
"Can you explain me everything again?"
"Why do you feel like that? What would you like me to do to help you?"
You must get your feelings under control before we can continue."
The Correct Answer is A
This response is appropriate because it seeks clarification and more information to help the nurse better understand the patient's statement. By asking for an example, the nurse can gain a better understanding of the patient's experience and identify appropriate interventions to help the patient manage their anxiety.
Option b is not an appropriate response as it does not seek clarification and instead asks the patient to repeat themselves.
Option c is partially appropriate but could be improved by asking more specific questions to help the patient articulate their feelings and needs.
Option d is not an appropriate response as it dismisses the patient's feelings and may cause the patient to feel unsupported and isolated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationalization is a defence mechanism in which a person attempts to justify or explain their behavior or actions in a way that makes them seem more acceptable or reasonable. In this case, the client is using rationalization by attributing their alcohol abuse to their job and the need to drink with clients at parties.
Option a. Compensation is a defense mechanism in which a person attempts to make up for a perceived weakness or deficiency by excelling in another area.
Option b. Suppression is a defense mechanism in which a person consciously chooses to avoid thinking about or dealing with unpleasant thoughts or feelings.
Option d. Reaction-formation is a defense mechanism in which a person behaves in a way that is opposite to their true feelings or desires.
Correct Answer is A
Explanation
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
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