When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Involve client in daily exercise program.

Ask the client to describe her depression.

Spend time sitting in silence with client.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is C

A.   Involving the client in a daily exercise program may be beneficial for depression but does not directly address the issue of delayed responses during questioning.
B.   Asking the client to describe her depression may be helpful for assessment purposes but does not address the immediate need of dealing with delayed responses.
C.   Spending time sitting in silence with the client allows the nurse to provide a supportive presence without pressure for immediate responses, which can be helpful for a client experiencing depression-related delays in communication.
D.   Observing for signs of possible psychosis is important but may not be indicated solely based on delayed responses; other symptoms would need to be present to warrant this concern.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Waiting until the client is completely calm is important because it allows the client to feel safe and secure, reducing anxiety and making it easier for them to open up about sensitive issues.
B. Asking difficult questions first is not typically advised as it can increase anxiety and make the client less likely to disclose information. It's important to build rapport and trust before tackling more challenging topics.
C. Using silence as a tool can give the client time to think and process their thoughts, which can lead to more meaningful communication. It also shows the nurse is patient and willing to listen.
D. Speaking with the client in private ensures confidentiality and helps establish a safe space where the client feels comfortable sharing personal information without fear of judgment or exposure.
E. Observing nonverbal behavior and reacting accordingly is crucial as it can provide insights into the client's emotional state and help the nurse respond in a way that is empathetic and supportive.
F. Asking several questions in a row can overwhelm the client and make it difficult for them to provide thoughtful answers. It's better to ask one question at a time and allow the client to fully respond before moving on to the next question.

A. Client claims that she was forced to participate in sexual intercourse. B. Client reported that she had sexual relations against her will. C. Client has been sexually assaulted. D. Client states, "My date raped me tonight."

Correct Answer is D

Explanation

Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.

Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.

Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.

Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.

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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client Exhibits In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

Correct Answer is D

Explanation

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?