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 C
Explanation
Validation is a technique used to acknowledge and validate the emotions and experiences of individuals with dementia, even if their thoughts or perceptions do not align with reality. In this scenario, the nurse responds by saying, "You miss your mother," which shows understanding and empathy toward the client's emotions. The nurse is validating the client's feelings rather than attempting to correct or redirect their thoughts.
A. Orientation to reality involves providing factual information and attempting to reorient individuals with dementia to the present time, place, and situation.
B. Remotivation is a technique used to stimulate memories and engage individuals with dementia in meaningful activities.
D. Guided imagery involves using vivid language and descriptive prompts to guide individuals into imagining pleasant or calming scenes.
Correct Answer is B
Explanation
Building trust and rapport with a suspicious client takes time and consistency. By setting aside short, frequent times each day to spend with the client, the nurse demonstrates reliability, availability, and a commitment to the client's well-being. This approach allows the client to gradually develop trust and feel more comfortable interacting with the nurse.
The other options are not appropriate actions:
A. Waiting for the client to initiate interactions with the nurse may result in limited or no engagement, as the client's suspicion may hinder their willingness to reach out. It is important for the nurse to take an active role in building the therapeutic relationship.
C. Disclosing personal information to the client is not recommended. The nurse should maintain professional boundaries and focus on the client's needs and concerns rather than sharing personal details that may compromise the therapeutic relationship or create an imbalance of power.
D. Telling the client that he reminds the nurse of her father may inadvertently trigger the client's suspicious thoughts and reinforce their mistrust. Making such personal comparisons is not appropriate and can hinder the establishment of a therapeutic relationship. It is important to focus on the client's individual experiences and needs rather than making personal connections.
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