A patient with cognitive impairment, who has been a widow for 30 years, is desperately trying to leave the facility, stating, “I have to go home to cook dinner before my husband gets home from work.”. How should the nurse intervene using validation therapy?

Choice A rationale
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
Choice B rationale
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
Choice C rationale
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
Choice D rationale
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.

Choice A rationale
Reviewing diagnostic test results is a crucial method for gathering data during the assessment phase of the nursing process. These results can provide valuable insights into the client’s health status and help to guide the planning and implementation of care.
Choice B rationale
Interviewing the client and significant others is another important method for data collection. This can help to gather information about the client’s symptoms, lifestyle, and personal history, which can all inform the care provided.
Choice C rationale
Performing a physical assessment is a key part of data collection in the nursing process. This involves examining the client’s physical condition and looking for any signs of illness or injury.
Choice D rationale
Interpreting the behaviors of the client is also a crucial part of data collection. This can provide insights into the client’s mental and emotional state, which can be particularly important in mental health nursing.