A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:
Say to the interrupting patient, “I am not available to talk with you at the present time”
End the unproductive session with the current patient and spend time with the patient who has just interrupted
Invite the interrupting patient to join in the session with the current patient
Tell the patient who interrupted, “This session will be 5 more minutes; then, I will talk with you”
The Correct Answer is D
Choice A reason: Bluntly stating unavailability dismisses the interrupting patient’s needs without offering a solution, potentially escalating distress. This approach lacks therapeutic communication, as it fails to acknowledge the patient’s urgency or provide a clear plan, which is critical in maintaining trust in a mental health setting.
Choice B reason: Ending the current session prematurely disrespects the silent patient’s therapeutic process. Silence may reflect processing or discomfort, requiring time to build trust. Abruptly shifting focus undermines the current patient’s care, potentially worsening their mental health and disrupting the therapeutic relationship.
Choice C reason: Inviting the interrupting patient to join violates confidentiality and disrupts the current patient’s safe space. Combining sessions without consent breaches ethical principles, potentially causing discomfort or mistrust, which hinders therapeutic progress for both patients in a mental health context.
Choice D reason: Acknowledging the interruption and scheduling a follow-up in 5 minutes respects both patients’ needs. It maintains the current patient’s therapeutic time while addressing the interrupting patient’s urgency, ensuring fairness and trust. This approach upholds ethical care and supports a therapeutic environment for mental health treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While behavior acceptability varies across cultures, this statement does not fully define mental health or illness. Cultural norms influence behavior interpretation, but mental health involves emotional and psychological well-being, not just cultural acceptability, making this option incomplete as a definition of mental health or illness.
Choice B reason: Mental health is characterized by emotional, psychological, and social well-being, reflected in adaptive coping strategies like problem-solving or seeking support. This holistic state enables individuals to manage stress and function effectively, making this statement a comprehensive and accurate description of mental health in contrast to mental illness.
Choice C reason: Engaging in fantasies is not inherently indicative of mental illness, as it can be a normal part of creativity or coping. Only when fantasies disrupt functioning or reflect delusions does it suggest illness. This statement is inaccurate, as it overgeneralizes a common behavior as pathological.
Choice D reason: Determining mental health or illness via verbal and nonverbal communication is complex and not always reliable. Cultural, individual, and contextual factors obscure interpretation, and clinical assessment requires comprehensive evaluation beyond communication, making this statement inaccurate as a definitive method for assessing mental health status.
Correct Answer is B
Explanation
Choice A reason: Hypocalcemia may occur in AKI due to impaired vitamin D activation, but it is not a primary concern in the diuresis phase, where kidneys produce large urine volumes. Calcium imbalances are less immediate than fluid losses, which can rapidly destabilize hemodynamics during this phase.
Choice B reason: In the diuresis phase of AKI, kidneys regain function, producing excessive urine, which can lead to hypovolemia. Fluid loss depletes intravascular volume, causing hypotension, tachycardia, and organ hypoperfusion. Monitoring is critical to prevent dehydration and ensure adequate fluid replacement to maintain hemodynamic stability during recovery.
Choice C reason: Increased blood pressure is more common in the oliguric phase of AKI due to fluid overload. In the diuresis phase, excessive urine output reduces volume, potentially lowering blood pressure. Hypertension is not a typical complication during this phase, making it an incorrect focus for monitoring.
Choice D reason: Hyperkalemia is a concern in the oliguric phase of AKI due to reduced potassium excretion. In the diuresis phase, increased urine output facilitates potassium clearance, reducing hyperkalemia risk. Hypovolemia from excessive fluid loss is a more immediate concern during this phase of AKI recovery.
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