A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking.
Which action should the nurse implement?
Postpone the client interview until the next day.
Document the client's paranoid behavior.
Attempt to ask the client simple questions.
Ask another nurse to talk with the client.
The Correct Answer is C
Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A: Asking the client why she checks the locks may provide insight into her anxieties but does not directly address the behavior or its impact on her daily functioning.
- B: Determining the type and size of the locks does not address the client's behavior or the underlying anxiety causing the behavior.
- C: Discussing checking the time frequently could help with time management but does not address the compulsive behavior or its root cause.
- D: Planning a list of activities to be carried out daily can help the client establish a routine, which may reduce anxiety and the need for repetitive checking. This approach encourages the client to focus on tasks and manage time more effectively, potentially reducing the impact of her compulsive behaviors on daily functioning.
Correct Answer is D
Explanation
Choice A Rationale:
While emotional expression and ventilation can be therapeutic, it may not be the most appropriate coping strategy for someone with depression who may already be overwhelmed by negative emotions. Ventilating emotions without a structured approach might not provide the desired relief and can even exacerbate feelings of distress.
Choice B Rationale:
This choice may not be suitable for someone with depression because it could lead to further neglect of their own needs and contribute to feelings of guilt or exhaustion.
Choice C Rationale:
While relaxation techniques can be helpful, reducing the effort to solve problems may not be the most effective strategy for individuals with depression. Avoidance of problems can perpetuate feelings of helplessness and hopelessness.
Choice D Rationale:
For a client with depression who is struggling with handling personal circumstances, focusing on small achievable tasks can be a helpful coping strategy. Breaking down larger problems into manageable steps can reduce feelings of overwhelm and gradually improve the client's sense of accomplishment and self-efficacy.
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