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.”

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Reviewing the client's toxicology laboratory report is not the priority action in this situation. While assessing toxicology can provide valuable information, the immediate concern is the client's safety due to their admission of thoughts of self-harm with a plan. Toxicology can be relevant but addressing the immediate risk takes precedence.

Choice B rationale:

Initiating suicide precautions is the priority action in this case. The client's admission of thoughts of self-harm with a plan indicates a high risk for suicide. Suicide precautions involve closely monitoring the client, removing any potential means of self-harm, and providing a safe environment. Addressing the client's immediate safety is of utmost importance.

Choice C rationale:

Making a contract with the client for eating behavior is not the priority action in this situation. While eating behavior might be a concern for some individuals with borderline personality disorder, depression, and substance abuse, the client's current statement about self-harm takes precedence. Ensuring the client's safety comes before addressing other aspects of their care.

Choice D rationale:

Administering the Hamilton Depression Scale is not the priority action in this scenario. While assessing the severity of the client's depression is important, the immediate concern is their safety due to the expressed thoughts of self-harm. Once the client's safety is ensured, further assessment and evaluation can take place.

A. Phase IV. B. Phase I. C. Phase III. D. Phase I.

Correct Answer is C

Explanation

The correct answer is choice C: "Phase III."

Choice A rationale:

Phase IV of the cycle of battering is the reconciliation phase, where tension is diffused after the explosion of violence. This does not align with the description provided in the statement.

Choice B rationale:

This response repeats the incorrect option from the question stem.

Choice C rationale:

The description of the woman sensing the man's declining tolerance for frustration, his increasing anger, quick apologies, and the woman's attempts to avoid his anger fits with Phase III. This phase, often referred to as the acute battering incident, involves the escalation of tension and the actual violent episode.

Choice D rationale:

This response repeats the incorrect option from the question stem.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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