A nurse is observing & newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?

Tell me about the concerns that you have regarding your relationship."

"Relationship difficulties are stressful and require effort to resolve."

"We could develop a plan for how to talk about this with your partner."

"You should try to see your partner's point of view before your own."

Answer and Explanation

The Correct Answer is D

A. "Tell me about the concerns that you have regarding your relationship."

This choice is an appropriate and open-ended question that encourages the client to express their feelings and concerns. It helps in building rapport and understanding the client's perspective.

B. "Relationship difficulties are stressful and require effort to resolve."

This choice acknowledges the challenges of relationship difficulties and conveys a supportive and empathetic attitude. It is a reasonable and non-biased statement.

C. "We could develop a plan for how to talk about this with your partner."

This choice suggests a proactive approach to address the client's concerns and promote effective communication. It is a helpful and appropriate statement.

D. "You should try to see your partner's point of view before your own."

This statement implies a biased approach, suggesting that the client should prioritize their partner's perspective over their own. While empathy and understanding are important in relationships, it's not appropriate for a healthcare professional to imply that one perspective is more important than the other. The nurse should encourage open communication and understanding from both sides rather than favoring one viewpoint.

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Correct Answer is C

Explanation

A. The client is unwilling to accept that treatment is needed.

This alone may not be sufficient to keep the client under a 72-hour hold. While a person's refusal to accept treatment may indicate a need for care, it might not meet the criteria for involuntary commitment unless there is an immediate danger to the individual or others.

B. The client states that she does not like the neighbor.

Disliking a neighbor is not typically a sufficient reason to place someone under a 72-hour psychiatric hold. The criteria for involuntary commitment usually revolve around a person's potential to harm themselves or others due to their mental state.

C. The client is a danger to herself or others.

Explanation:

In many jurisdictions, a 72-hour psychiatric hold, also known as an involuntary psychiatric hold or emergency detention, allows mental health professionals to detain a person who is considered a danger to themselves or others due to their mental condition. This is done to ensure the safety of the individual and those around them. The hold provides a brief period during which a psychiatric assessment can be conducted to determine the appropriate course of action for the person's mental health treatment.

D. The client states that she plans to move out of the state immediately.

While this statement might raise concerns about the client's stability, it generally would not meet the criteria for a 72-hour hold unless there is clear evidence that the client's immediate move would pose a risk to their own safety or the safety of others. The hold is more focused on imminent danger rather than potential future actions.

A. Discuss self-defense techniques with the client. B. Give the client a bed bath prior to physical examination. C. Inform the client photographs of injuries are required for a police report. D. Ask the client to describe the situation.

Correct Answer is D

Explanation

A. Discuss self-defense techniques with the client: Incorrect

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

B. Give the client a bed bath prior to physical examination: Incorrect

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

C. Inform the client photographs of injuries are required for a police report: Correct

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

D. Ask the client to describe the situation: Correct

It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.

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A nurse is observing & newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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