A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?
"You should try to see your partner's point of view before your own.”
"Relationship difficulties are stressful and require effort to resolve.”
"We could develop a plan for how to talk about this with your partner.”
"Tell me more about the concerns that you have regarding your marriage.”
The Correct Answer is A
Choice A rationale:
This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.
Choice B rationale:
Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.
Choice C rationale:
Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.
Choice D rationale:
Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Other than possible coordination problems, the client's psychomotor skills are not affected. Severe Intellectual Disability (ID) is characterized by significant limitations in intellectual functioning as well as adaptive behaviors. Coordination problems are not a primary characteristic of severe ID. The main focus is on cognitive and adaptive deficits.
Choice B rationale:
The client communicates wants and needs by "acting out behaviors." Severe ID can lead to challenges in effective communication. "Acting out behaviors" such as tantrums, aggression, or other disruptive actions might be the client's way of expressing themselves when they are unable to communicate verbally or effectively due to their cognitive limitations.
Choice C rationale:
The client can perform some self-care activities independently. Severe ID typically involves significant impairments in adaptive functioning, which includes self-care activities. The ability to perform some self-care activities independently is not consistent with the characteristics of severe ID.
Choice D rationale:
The client has advanced speech development. Severe ID is associated with delayed or impaired speech and language development. Advanced speech development would be contradictory to the diagnosis of severe ID, as this condition is characterized by substantial limitations in communication skills.
Correct Answer is A
Explanation
The correct answer is choice A: "Assess the client's need for assistance with ADLS."
Choice A rationale:
Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.
Choice B rationale:
Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.
Choice C rationale:
Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.
Choice D rationale:
Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.
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