A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Tell me what is concerning you."

"Your husband is making really good progress."

"Did your husband say something to upset you?"

"Crying helps us let things out and we feel better."

Answer and Explanation

The Correct Answer is A

A. "Tell me what is concerning you."

This response is the most therapeutic option. It invites the spouse to share their concerns and feelings, showing empathy and active listening. It opens the door for effective communication and understanding the spouse's perspective.

B. "Your husband is making really good progress."

While this response provides information about the husband's progress, it doesn't directly address the spouse's concerns or feelings. The spouse's emotional state needs to be acknowledged and explored before discussing the husband's progress.

C. "Did your husband say something to upset you?"

This response makes an assumption that the husband said something to upset the spouse. It might come across as accusatory or dismissive of the spouse's feelings. It's important to give the spouse the opportunity to express their emotions in their own words.

D. "Crying helps us let things out and we feel better."

This response offers a general statement about crying, but it doesn't directly address the spouse's concerns or invite further conversation. While it's true that crying can be cathartic, the focus here should be on understanding the spouse's specific worries.

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Correct Answer is A

Explanation

A. Clients who are involuntarily admitted to a mental health unit retain their rights, including the right to informed consent. This means they must be informed about their treatment, including medications, procedures, and potential risks, and they have the right to accept or refuse treatment, unless a court order states otherwise.

B.Involuntary admission does not automatically mean forced treatment. Clients can refuse medications, unless they are deemed a danger to themselves or others, in which case a court order may be obtained to administer medication.

C.Restraint laws apply equally to all clients, regardless of admission status. Restraints must always be used as a last resort and require a provider’s order, regular assessments, and documentation.

D.Involuntary hospitalization has legal time limits, and court review is required for extended hospitalization. The length of stay varies based on state laws and judicial rulings.

A. identify the client's nutritional status. B. Provide a structured environment for the client. C. Plan a therapeutic diet for the client D. Request à mental health consult.

Correct Answer is A

Explanation

A. Identify the client's nutritional status.

Explanation:

Given the significant weight loss and the client's distorted belief about her body image (believing she is fat despite losing weight), it is crucial to assess the client's nutritional status first. Rapid weight loss and distorted body image are characteristic features of an eating disorder, such as anorexia nervosa. The nurse needs to determine the extent of malnutrition and potential medical complications related to inadequate nutrition. This assessment will guide the subsequent interventions.

Why the other choices are incorrect:

B. Provide a structured environment for the client.

While providing a structured environment can be important in managing eating disorders, such as anorexia nervosa, it is not the first priority. Understanding the client's nutritional status and medical condition takes precedence.

C. Plan a therapeutic diet for the client.

Planning a therapeutic diet may be part of the client's care plan, but without understanding the underlying nutritional status and potential eating disorder, creating a diet plan may not be effective or appropriate.

D. Request a mental health consult.

While a mental health consult is important for addressing the client's distorted body image and potential eating disorder, it should follow the assessment of nutritional status. The nutritional assessment provides critical information for both medical and psychological interventions.

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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

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Naxlex Comprehensive Predictor Exams

A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?

Correct Answer is A

Explanation

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is A

Explanation

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