A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?
"I will assist you in getting out of bed and getting dressed."
"You can remain in bed until you feel well enough to join the milieu."
"The unit rules state that clients may not remain in bed."
"If you don't participate in your care, you will not get better."
The Correct Answer is A
The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.
The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.
The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.
The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The response "Let's work together to devise a schedule that is convenient for you on a daily basis" demonstrates a collaborative and patient-centered approach. It acknowledges the client's difficulty in following a medication regimen and suggests finding a solution that works for the client's lifestyle and needs. By involving the client in the process and considering their preferences and challenges, the nurse can increase the chances of medication adherence.
The response "You really should work hard to stay on the schedule we establish here" may come across as judgmental and may not address the underlying reasons for the client's difficulty in medication adherence. It does not promote a collaborative and supportive environment.
The response "I wouldn't worry about what you've done in the past. You'll do just fine this time" dismisses the client's concerns and does not provide practical strategies to improve medication adherence. It does not address the client's specific challenge or offer any support.
The response "Why do you find it difficult to take your medications if they improve your condition?" is a probing question that seeks to understand the client's reasons for struggling with medication adherence. While it may be important to explore the underlying reasons, it should be followed by a supportive and collaborative approach to finding solutions.
Correct Answer is D
Explanation
Autonomy is the ethical principle that upholds an individual's right to make decisions about their own care and treatment. Respecting autonomy means acknowledging and honoring a person's right to make choices based on their own values, beliefs, and preferences. By importing a client's wishes to refuse prescribed treatments, the nurse is recognizing and respecting the client's autonomy. This shows that the nurse values the client's right to make decisions about their own healthcare and supports their choice, even if it may differ from what the nurse may recommend.
Incorrect:
A. Spending extra time to calm an agitated client demonstrates the ethical principle of beneficence, which is the duty to promote the well-being and welfare of the client.
B. Ensuring that a client understands expectations for group participation relates to the ethical principle of fidelity, which involves maintaining trust and keeping promises to the client.
C. Describing the adverse effects of a client's medications is important for informed consent and promoting understanding, but it does not directly involve the client's autonomy unless it is accompanied by a discussion of the client's choices and preferences regarding medication.
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