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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

This response acknowledges the client's need for assistance while redirecting the focus towards exploring alternative solutions. It demonstrates the nurse's willingness to help and initiates a collaborative problem-solving approach. By engaging in a discussion about available resources, the nurse can help the client explore options such as home delivery services, community support programs, or involving family and friends in assisting with grocery shopping.

Let's review the other options and explain why they are not the most appropriate responses:

A. "I won't be able to shop for you today because I have to get home to my family." This response lacks empathy and doesn't address the client's needs. It is important for the nurse to prioritize the client's well-being and explore appropriate solutions rather than providing personal reasons for not being able to assist.

B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response overlooks the client's current limitations and implies that the client should solely rely on their own abilities, which may not be feasible or practical for the client.

D. "I would be happy to do whatever I can to help you." While this response conveys the nurse's willingness to assist, it is important to remember that shopping and performing personal errands are typically outside the scope of a home care nurse's responsibilities. It is more appropriate to explore other resources and options to address the client's needs effectively.

A. Explore the truth of the client's statements. B. Establish a therapeutic nurse-client relationship. C. Set behavioral limits for the client D. Show the client around the unit and introduce her to other clients.

Correct Answer is C

Explanation

The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:

A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.

B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.

D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.

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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?

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Correct Answer is C

Explanation

A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Correct Answer is C

Explanation

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