A nurse is caring for a client on the Mental Health Unit. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?

“You should rest until you feel able to join the group.”

“I will help you get ready, and then you can rest after activities.”

“If you do not get out of bed, you will not receive your meal.”

“You really need to follow the rest of the unit and get out of bed.”

Answer and Explanation

The Correct Answer is B

Choice A Reason: While this response may seem compassionate, it does not encourage the client to engage in activities that could benefit their mental health. Allowing the client to remain isolated may reinforce feelings of helplessness or depression. It is important to motivate clients to participate in therapeutic activities to promote their recovery.

Choice B Reason: This response is supportive and offers a compromise. It acknowledges the client’s current state and provides assistance, while also gently encouraging participation in activities. By offering help and allowing for rest afterward, the nurse is using an empathetic approach to facilitate the client’s involvement in the unit’s programs.

Choice C Reason: This response is coercive and could be considered a threat. It is not therapeutic to withhold basic needs such as meals as a form of punishment or to force compliance. Such an approach can damage the nurse-client relationship and is not conducive to the client’s recovery.

Choice D Reason: This response may come across as dismissive and demanding. It does not offer support or acknowledge the client’s feelings. Telling the client what they “need” to do without offering help or understanding can lead to resistance and a lack of trust in the nurse-client relationship.

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Correct Answer is A

Explanation

Choice A reason:
Talking directly to the client and setting clear boundaries is a therapeutic approach. It respects the client's autonomy while also addressing the behavior that is affecting the therapeutic environment. By identifying specific limits, the nurse helps the client understand the consequences of their actions and the importance of maintaining a respectful and honest communication with others.

Choice B reason:
Discussing the problem in a community meeting could be helpful, but it should not be the initial action. This approach might inadvertently shame or embarrass the client in front of peers, which could exacerbate the situation. It's important to address the behavior privately before involving the larger group.

Choice C reason:
Escorting the client to their room each time they socialize could be seen as punitive and may not address the underlying reasons for the lying behavior. It could also isolate the client from social interactions that are an essential part of the healing process.

A. Adventitious B. Maturational C. Developmental D. Situational

Correct Answer is D

Explanation

Choice A Reason:
An adventitious crisis is not applicable here. This type of crisis is usually a result of a natural or man-made disaster, war, or major accident, which is not the case with the client's situation.

Choice B Reason:
Maturational crises are associated with life transitions or developmental stages, such as retirement or menopause. While the client is older, the crisis is not due to a normal life transition but rather an unexpected event.

Choice C Reason:
Developmental crises occur as a person moves through the stages of life. The client's crisis does not stem from a developmental issue but from an external event that has disrupted their life.

Choice D Reason:
Situational crises arise from external sources that an individual may face throughout life, such as the death of a loved one, loss of a job, or severe illness. The client's inability to cope with the sudden death of their spouse is a situational crisis.

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A nurse is caring for a client on the Mental Health Unit. The client refuses to get out of bed, go to activities, or participate in any of the unit’s programs. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for an older adult client following the sudden death of their spouse. The client feels stuck in their ability to deal with work and family responsibilities. The nurse should recognize that the client is experiencing which type of crisis?

Correct Answer is D

Explanation

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