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 ["A","B","F","G"]
Explanation
From the given information, the nurse should include the following interventions in the plan of care for the client with dementia:
● Obtain client's weight weekly: Regular weight monitoring helps assess the client's nutritional status and detect any significant changes that may require intervention.
● Offer the client finger foods for meals: Finger foods can be easier for the client to handle and consume independently, promoting independence and self-feeding.
● Encourage the client to take deep breaths when feeling agitated: Deep breathing exercises can help the client manage their agitation and promote relaxation.
● Assess client's memory every shift: Regular assessment of the client's memory allows for monitoring any changes or decline, which helps in planning appropriate interventions and providing necessary support.
The following interventions should be avoided:
● Speak loudly when addressing the client: Speaking loudly may cause confusion or agitation in the client. Instead, it is recommended to use a calm and reassuring tone of voice.
● Give long tasks at a time to the client: Clients with dementia often have difficulty with concentration and memory. Providing long tasks may overwhelm them and contribute to their frustration. Breaking tasks into smaller, manageable steps is more appropriate.
● Turn the client's TV on at night when they are unable to sleep: It is generally recommended to create a quiet and calming environment for sleep. The TV may interfere with the client's sleep and contribute to increased agitation or confusion.
Correct Answer is D
Explanation
Asking the client how they feel about being discharged encourages open communication and provides an opportunity for the client to express their emotions and thoughts about leaving the
hospital. It shows that the nurse values the client's perspective and allows for further discussion and support if needed. This response promotes client-centered care and acknowledges the client's experience during the hospitalization.
The other options are less appropriate:
A. "I know you will do well living out in the community" assumes the client's feelings and may not accurately reflect their experience or emotions about the discharge.
B. "I will send you a note in a few weeks" focuses on the nurse's future action rather than actively engaging with the client's expression of gratitude.
C. "Aren't you excited about being discharged today?" assumes the client's emotional state and may not consider the potential range of emotions the client could be experiencing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
