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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale: Disrupting group activities is a concerning behavior but may not necessitate constant observation. The key is to assess the potential for harm to self or others.

Choice B rationale: Refusing antipsychotic medications is a significant concern, but it alone may not warrant constant observation. The nurse needs to assess the client's overall behavior and the potential for harm.

Choice C rationale: Wandering into clients' rooms poses a risk to the safety of both the client and others. This behavior indicates a need for constant observation to prevent harm or inappropriate interactions.

Choice D rationale: Talking with nonsensical words is a symptom of the client's mental health condition but may not be the sole criterion for constant observation. The nurse should assess the overall risk to safety.

A. Altruism. B. Regression. C. Compartmentalization. D. Egocentrism.

Correct Answer is A

Explanation

Choice A rationale: Altruism involves addressing one's own needs through meeting the needs of others, and caring for the husband's aging parents is an example of this coping mechanism.

Choice B rationale: Regression involves reverting to an earlier stage of development, which is not evident in the scenario.

Choice C rationale: Compartmentalization is the defense mechanism of separating conflicting thoughts or feelings, which is not clearly identified in the scenario. Choice D rationale: Egocentrism involves seeing the world from only one's own perspective, which is not the primary issue in the scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is C

Explanation

A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

Correct Answer is A

Explanation

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

A client is admitted to the emergency department because of a possible overdose of methadone and benzodiazepines. The admission respiratory rate is 6 breaths/minute. Based on this finding, the nurse should prepare for which intervention?

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?