During the end-of-shift report the nurse notes that a client had been

During the end-of-shift report the nurse notes that a client had been very nervous and preoccu-pied during the evening and that no family visited. To determine the amount of anxiety that the client is experiencing, the nurse should respond:

1. “Would you like for me to call a family member to come support you?”
2. “Would you like to talk with another client who had the same surgery?”
3. “How serious do you think the illness you are experiencing really is?”
4. “You seem worried about something. Would it help to talk about it?”

ANSWER

ANS: 4
The nurse learns from the client both by asking questions and by making observations of nonver-bal behavior and the client’s environment. To determine the amount of anxiety the client is expe-riencing, the nurse gathers information from the client’s perspective. Noting that he seems wor-ried and offering to discuss it is the correct response. Asking if the client desires for family to be called is not assessing the client’s level of anxiety. The nurse should first focus on developing a trusting relationship with the client. If the nurse takes the client to visit someone who had the same surgery, the nurse would not be able to assess the client’s current level of anxiety. Asking the client about how serious he deems the illness to be is not the best response. It does not assess the amount of anxiety the client is currently experiencing.