Nokea
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, 'You are incompetent!' Which is the nurse's best response?
- A. Do you believe that I was the cause of your blood test being canceled?
- B. I see that you are upset, but I feel uncomfortable when you swear at me.
- C. Have you ever thought about ways to express anger appropriately?
- D. I'll give you some space. Let me know if you need anything.
Correct Answer: B
Rationale: In this scenario, the most appropriate response for the nurse is option B. By acknowledging the client's feelings and setting a boundary regarding inappropriate behavior, the nurse addresses the situation with empathy. This response demonstrates understanding of the client's emotions while also maintaining a professional standard by expressing discomfort with swearing. Option A could come off as defensive and may escalate the situation. Option C may be perceived as condescending and not immediately address the client's behavior. Option D, although offering space, does not directly address the inappropriate behavior and misses an opportunity to set a professional boundary.
You may also like to solve these questions
A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?
- A. You shouldn't worry about that. It's not real.
- B. I don't see any FBI agents, but it sounds like you're feeling frightened.
- C. Let's talk about something else to take your mind off of it.
- D. Why do you think the FBI is watching you?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client diagnosed with panic disorder is receiving discharge teaching from a healthcare provider. Which statement by the client indicates an accurate understanding of the teaching?
- A. I should avoid caffeine and other stimulants.
- B. I should take my medication only when I feel anxious.
- C. I should use relaxation techniques to manage anxiety.
- D. I should avoid exercising to prevent triggering anxiety.
Correct Answer: A
Rationale: The correct answer is A. Avoiding caffeine and other stimulants is crucial for clients with panic disorder as these substances can exacerbate anxiety symptoms. Caffeine can trigger or worsen anxiety, leading to increased heart rate and restlessness. By eliminating stimulants, the client can better manage their anxiety levels and reduce the risk of panic attacks. Choices B, C, and D are incorrect because taking medication only when feeling anxious may lead to inconsistent treatment, using relaxation techniques alone may not be sufficient for managing panic disorder, and avoiding exercise can actually be counterproductive as regular physical activity can help reduce anxiety and stress levels.
A client is experiencing panic attacks. Which intervention should the nurse implement to help the client manage anxiety?
- A. Encourage the client to avoid situations that trigger anxiety.
- B. Encourage the client to practice deep breathing exercises.
- C. Encourage the client to take anti-anxiety medication as prescribed.
- D. Encourage the client to engage in regular physical activity.
Correct Answer: B
Rationale: During panic attacks, deep breathing exercises can help the client manage anxiety effectively by promoting relaxation and reducing the intensity of symptoms. Encouraging the client to practice deep breathing can provide a quick and accessible strategy to cope with the immediate distress of a panic attack. Choices A, C, and D are incorrect because avoiding triggering situations may reinforce avoidance behavior, anti-anxiety medication is not the first-line intervention during a panic attack, and engaging in physical activity may not be feasible or effective during an acute episode of panic.
A client has been diagnosed with borderline personality disorder. Which behavior is characteristic of this disorder?
- A. Excessive need for attention
- B. Instability in relationships
- C. Fear of abandonment
- D. Lack of interest in activities
Correct Answer: B
Rationale: The correct answer is B: Instability in relationships. Individuals with borderline personality disorder often exhibit instability in their relationships, characterized by intense and unstable interpersonal connections, oscillating between idealization and devaluation. This pattern can lead to frequent conflicts, dramatic emotional shifts, and difficulties maintaining stable relationships. Choices A, C, and D are incorrect. While individuals with borderline personality disorder may also have an excessive need for attention, fear of abandonment, or lack of interest in activities, the hallmark feature defining this disorder is the instability in relationships.
A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?
- A. Implement a no-harm contract with the client.
- B. Monitor the client closely for signs of self-harm.
- C. Encourage the client to participate in recreational activities.
- D. Encourage the client to maintain a structured daily routine.
Correct Answer: A
Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.