When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn’t want to do anything. It has been a really difficult time for me.” Which response should the nurse provide?

Why do you think you have a hostile work environment?

Have you considered resigning from your position?

Have the feelings associated with these events brought you to the clinic?

How have you responded to those in your work environment about these events?

Answer and Explanation

The Correct Answer is C

A.   This question may be perceived as confrontational. It is essential to explore the client's feelings and experiences first.
B.   Asking about resignation is premature at this stage. Exploring feelings and experiences is more appropriate initially.
C. This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic.
D.   This question is more focused on the client's actions rather than exploring the emotional impact of the events. The nurse should first understand the client's feelings before addressing actions or solutions.

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Correct Answer is C

Explanation

A. Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B. Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D. Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.

A. Help the client identify thoughts that may be triggers. B. Explore past behaviors that have provided relief. C. Attempt to distract to another focus or activity. D. Speak calmly to the client stating assurance of safety.

Correct Answer is D

Explanation

A. Identifying triggers may be beneficial, but the client is currently in a state of severe anxiety, and immediate intervention to address the symptoms is needed.
B. Exploring past behaviors can be addressed later; the immediate focus should be on managing the acute symptoms of anxiety.
C. Attempting to distract the client can be helpful, but providing reassurance and addressing safety concerns take precedence.
D. Speaking calmly to the client and providing assurance of safety is an appropriate first step in managing severe anxiety. Once the client is more settled, other interventions can be explored.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Correct Answer is D

Explanation

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)