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 B
Explanation
Clients have the right to make informed decisions about their own healthcare, including the right to refuse treatment. It is important to respect the client's autonomy and honor their decision if they choose to refuse the treatment. The nurse should provide the client with information about the potential benefits and risks of the treatment, as well as any alternatives, and support the client in making an informed decision.
Let's examine why the other choices are incorrect:
A. "You will be discharged sooner if you have the prescribed ECT treatments." This statement does not address the client's right to refuse treatment and instead focuses on potential consequences of refusing. It is important to respect the client's autonomy and prioritize their right to make decisions about their own healthcare.
C. "You are admitted to a mental health facility and must follow the provider's orders." While clients in a mental health facility may have certain treatment plans, including ECT, it is still important to respect their right to refuse treatment. Admitting to a facility does not negate the client's right to make decisions about their own care.
D. "You have already signed the consent form, so you cannot refuse today's treatment." Signing a consent form does not mean that the client loses their right to refuse treatment. Consent forms are signed to acknowledge that the client has been provided with information about the treatment and has agreed to undergo it voluntarily. However, the client still has the right to change their mind and refuse the treatment at any time.
Correct Answer is A
Explanation
When assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious, the nurse should prioritize assessing the client's suicide risk. This is because the client's symptoms, particularly feelings of depression and anxiety, can indicate a higher risk for self-harm or suicide. Assessing suicide risk is crucial to ensure the client's safety and provide appropriate interventions if needed.
incorrect:
B. Coping abilities: While assessing coping abilities is important to understand how the client manages stress and emotional challenges, it is secondary to assessing suicide risk. Coping abilities can be explored in subsequent assessments to determine the client's resilience and available resources for support.
C. Psychiatric history: Although understanding the client's psychiatric history is relevant for comprehensive care, it may not be the most immediate concern during the admission process. Assessing suicide risk takes precedence to ensure the client's safety.
D. Support systems: While assessing the client's support systems is valuable for understanding the available network of support, it should not take priority over assessing suicide risk. The client's immediate safety and potential need for intervention require immediate attention.
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