The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?
Walt for the client to respond.
Ask if the client heard the question.
Ask a different question.
Return at a later time to talk.
The Correct Answer is A
Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.
Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.
Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.
Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
Correct Answer is A
Explanation
Choice A rationale: Thiamine (vitamin B1) is the appropriate medication for Wernicke Korsakoff syndrome, as it addresses thiamine deficiency associated with chronic alcohol use, which can contribute to neurological symptoms.
Choice B rationale: Chlordiazepoxide is a benzodiazepine used for alcohol withdrawal symptoms but does not address the underlying thiamine deficiency in Wernicke Korsakoff syndrome.
Choice C rationale: Clonidine is not indicated for the treatment of Wernicke-Korsakoff syndrome; it is primarily used for managing withdrawal symptoms in opioid or alcohol dependence.
Choice D rationale: Carbamazepine is not the appropriate medication for Wernicke Korsakoff syndrome; it is commonly used for mood stabilization in conditions like bipolar disorder.
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