The client exhibits a flat affect, psychomotor retardation, and a depressed mood. The nurse attempts to engage the client in an interaction, but the client does not respond to the nurse. Which response by the nurse is most therapeutic?
I will sit here with you for 10 minutes.
will find someone else for you to talk with.
I will come back a little bit later
I will get you something to read
The Correct Answer is A
A) I will sit here with you for 10 minutes: This response is the most therapeutic because it shows the nurse’s willingness to be present with the client without pressuring them for interaction. Sitting quietly with the client provides comfort and reassurance, acknowledging their feelings while respecting their need for space. It is important for clients with depression to feel supported, even if they cannot engage in conversation at the moment.
B) I will find someone else for you to talk with: While this response may seem considerate, it could be interpreted as abandoning the client or suggesting they are not worthy of the nurse's attention. The client might feel more isolated or rejected. The priority is to offer comfort and consistency, not to remove oneself from the situation immediately.
C) I will come back a little bit later: While giving the client some time and space is important, this response may not be as therapeutic as simply remaining with the client. It suggests the nurse is unwilling to be present now, which could make the client feel neglected. It’s better to offer calm and supportive presence at the moment, rather than withdrawing.
D) I will get you something to read: Offering something to read can be helpful for some clients, but in this situation, where the client is displaying a flat affect and psychomotor retardation, this response may be too focused on distracting or diverting the client from their emotional state. The priority is to stay with the client and offer a calm, supportive presence rather than immediately introducing distractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A) Defensive responses to questions: During the preassaultive stage, a client may become increasingly defensive and may respond aggressively or defensively to questions, indicating rising tension and frustration. These defensive responses can signal the client’s growing agitation, which can escalate if not addressed appropriately.
B) Lethargy: Lethargy is not typical in the preassaultive stage of violence. Instead, clients in this stage are more likely to exhibit signs of agitation and heightened energy, not a decrease in activity or alertness. Lethargy might indicate a different issue, such as depression or sedation from medications.
C) Disorientation: Disorientation is not a hallmark of the preassaultive stage. While a client may experience confusion or irrational thinking during an acute episode of mental illness, disorientation is more commonly associated with conditions like delirium or cognitive disorders, rather than the early signs of violence.
D) Agitation: Agitation is a classic sign of the preassaultive stage. The client may show physical signs of distress, such as fidgeting, pacing, or increased restlessness. Agitation often precedes violent outbursts, and it’s an important sign that the nurse must be vigilant about in order to intervene before the situation escalates.
E) Facial grimacing: Facial grimacing can be a physical manifestation of increasing tension and aggression, indicating discomfort or frustration. This is another sign that the client may be entering the preassaultive stage, where heightened emotional responses are often accompanied by visible, nonverbal cues of agitation.
Correct Answer is C
Explanation
A) Tardive dyskinesia: Tardive dyskinesia is a late-onset movement disorder that causes repetitive, involuntary movements, such as tongue protrusion or lip smacking. It typically develops after long-term use of antipsychotics like fluphenazine. Since the client reports restlessness shortly after starting the medication, this is unlikely to be tardive dyskinesia, which takes months to years to develop.
B) Pseudoparkinsonism: Pseudoparkinsonism is a side effect of antipsychotics that causes symptoms similar to Parkinson's disease, such as tremors, rigidity, and bradykinesia. While restlessness is not a hallmark symptom of pseudoparkinsonism, it could lead to a lack of coordination or stiffness, but it does not explain the client's feeling of being restless all the time.
C) Akathisia: Akathisia is a common side effect of antipsychotics, including fluphenazine. It is characterized by an intense feeling of restlessness and an inability to sit still, often accompanied by an urge to move. This matches the client's description of being restless and unable to sit still, making akathisia the most likely cause of their symptoms.
D) Acute dystonia: Acute dystonia involves painful, muscle spasms or abnormal postures, such as twisting of the neck or eyes rolling back, which can occur shortly after taking antipsychotics. However, this condition typically causes muscle rigidity or spasms rather than the restlessness that the client describes, making it less likely in this case.
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