As the discharge date for a client to leave gets closer, the client states, “I’m afraid to leave here. I’m afraid for my well-being and safety.” Which nursing statement is most supportive?

“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”

“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”

“You’ve had a month to come up with a plan to work on your well-being.”

“Hopefully you learned from being in counseling. I’m sure this will work out fine.”

Answer and Explanation

The Correct Answer is A

Choice A Reason:

“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”

This response is the most supportive because it acknowledges the client’s feelings and offers a proactive solution. By recognizing the difficulty of the transition and suggesting a plan to ensure the client’s safety, the nurse provides reassurance and practical support. This approach helps to build trust and shows empathy, which is crucial in a therapeutic relationship.

Choice B Reason:

“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”

While this response acknowledges the client’s fear, it focuses on policy rather than addressing the client’s immediate emotional needs. Extending the stay might not be feasible or beneficial in the long term. The primary goal should be to empower the client to feel safe and supported outside the facility.

Choice C Reason:

“You’ve had a month to come up with a plan to work on your well-being.”

This response can come across as dismissive and unsupportive. It implies that the client should have already resolved their fears, which may increase their anxiety and feelings of inadequacy. The focus should be on providing immediate support and reassurance rather than criticizing the client’s progress.

Choice D Reason:

“Hopefully you learned from being in counseling. I’m sure this will work out fine.”

This response is overly optimistic and does not address the client’s current fears. It provides false reassurance without offering any concrete support or solutions. The client needs to feel heard and supported, not just reassured that everything will be fine.

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Correct Answer is C

Explanation

Choice A Reason:

Obtunded describes a state where the patient has a decreased level of consciousness and is difficult to arouse. They may respond slowly and be somewhat confused. This level of consciousness is more severe than lethargy and typically requires more vigorous stimulation to elicit a response. The client’s ability to answer questions appropriately before falling back to sleep suggests a less severe impairment than obtundation.

Choice B Reason:

Stuporous refers to a condition where the patient is almost entirely unresponsive and can only be aroused by vigorous and repeated stimuli. This state is more severe than lethargy and obtundation. The client’s ability to respond appropriately to questions indicates a higher level of consciousness than stupor. Therefore, stuporous is not the correct description of the client’s condition.

Choice C Reason:

Lethargic describes a state where the patient is very drowsy but can be aroused to respond to questions and then falls back to sleep. This matches the client’s presentation as they are able to answer questions appropriately but fall asleep immediately afterward. Lethargy is a common level of altered consciousness in various medical conditions and is less severe than obtundation or stupor.

Choice D Reason:

Alert describes a state where the patient is fully awake, aware, and responsive to stimuli. The client’s tendency to fall back to sleep immediately after responding to questions indicates that they are not fully alert. Therefore, this term does not accurately describe the client’s level of consciousness.

A. The client diagnosed with a somatoform disorder should have any new medical complaint evaluated. B. The client diagnosed with a somatoform disorder can be easily cured with medication. C. The client diagnosed with a somatoform disorder has a real medical diagnosis for their symptoms. D. The client diagnosed with a somatoform disorder intentionally pretends to have physical symptoms.

Correct Answer is A

Explanation

Choice A Reason:

The client diagnosed with a somatoform disorder should have any new medical complaint evaluated.

This is the correct response. Clients with somatoform disorders often experience physical symptoms that cannot be fully explained by any underlying medical condition. However, it is crucial to evaluate any new medical complaints to rule out any actual medical conditions that may require treatment. This approach ensures that the client receives comprehensive care and that any potential medical issues are not overlooked.

Choice B Reason:

The client diagnosed with a somatoform disorder can be easily cured with medication.

This statement is incorrect. Somatoform disorders are complex and often require a multifaceted treatment approach, including psychotherapy, behavioral interventions, and sometimes medication to manage associated symptoms like anxiety or depression. There is no simple cure for somatoform disorders, and treatment typically focuses on managing symptoms and improving the client’s quality of life.

Choice C Reason:

The client diagnosed with a somatoform disorder has a real medical diagnosis for their symptoms.

While clients with somatoform disorders experience real and distressing symptoms, these symptoms are not typically linked to a diagnosable medical condition. The symptoms are believed to be related to psychological factors, and the focus of treatment is often on addressing these underlying psychological issues rather than finding a medical diagnosis.

Choice D Reason:

The client diagnosed with a somatoform disorder intentionally pretends to have physical symptoms.

This statement is incorrect. Clients with somatoform disorders do not intentionally fake their symptoms. Their symptoms are real to them and cause significant distress and impairment. The symptoms are not under the client’s conscious control, and they genuinely believe they are experiencing a medical condition.

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As the discharge date for a client to leave gets closer, the client states, “I’m afraid to leave here. I’m afraid for my well-being and safety.” Which nursing statement is most supportive?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is admitted to the inpatient psychiatric unit with a diagnosis of a somatoform disorder. Which statement does the nurse recognize as true about all somatoform disorders?

Correct Answer is A

Explanation

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:

Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?

A client is admitted to the Emergency Department (ED) after ingesting a large amount of diazepam. Which medication would the nurse expect the ED physician to order?

A client was recently diagnosed with mild Alzheimer’s disease. Which of the statements shared by the client’s child about their risk for Alzheimer’s disease indicates the need for re-teaching? (Select all that apply.)

The nurse recognizes that a function of the Mental Status Exam is to:

A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

An inpatient on the psychiatric unit is having a panic attack. An appropriate nursing intervention at this time would be to:

A client diagnosed with generalized anxiety disorder (GAD) is started on buspirone. Which statement made by the client indicates teaching has been effective? The client verbalizes that: