An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?
"You are probably right. Soiling the bed is a way of getting attention from the nursing staff."
"Tell me what makes you feel the client is doing this on purpose?"
"Why don't you spend more time with the client if you think that she is trying to get attention?"
"Next time this happens, tell me and I'll talk to the client about his behavior."
The Correct Answer is B
When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.
Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.
Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.
Correct Answer is A
Explanation
initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.
Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.
Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.
Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.
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