Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?
Building a trusting relationship
Searching her belongings
Orienting her to the unit
Helping her settle into her room
The Correct Answer is B
A. Building a trusting relationship: Establishing trust is essential in therapeutic relationships, especially with clients at risk for self-harm. However, ensuring the client’s immediate safety by searching belongings takes precedence to protect the client from further harm.
B. Searching her belongings: This is the first priority to ensure Patty’s immediate safety and prevent access to any objects she could use to harm herself. This action addresses the immediate risk and creates a safer environment for her.
C. Orienting her to the unit. Orientation to the unit helps the client feel more comfortable and understand the rules and layout of the facility, but it is not as urgent as ensuring her safety upon admission.
D. Helping her settle into her room: Assisting Patty in getting comfortable is important for her overall well-being but is secondary to securing her environment by removing any potentially harmful items.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"Your provider is very knowledgeable, if he prescribes chemotherapy, it's the best treatment for you.” This response may be perceived as dismissive of the client's concerns and preferences. It is important to acknowledge and explore the client's perspective rather than making assumptions.
Choice B Reason:
"Using nontraditional treatments is not a good deal, rather you avoid that route.” This response is directive and may be seen as judgmental. It does not invite the client to share their concerns openly and may hinder effective communication.
Choice C Reason:
"Tell me more about your concerns about taking chemotherapy.” This response encourages open communication and demonstrates active listening. It allows the nurse to understand the client's concerns and preferences regarding chemotherapy. This approach supports a collaborative decision-making process, respects the client's autonomy, and helps build trust in the nurse-client relationship.
Choice D Reason:
"A lot of people think nontraditional treatments will work, they end up regretting that choice. “This response introduces a potentially guilt-inducing statement and may create a negative atmosphere. It does not encourage the client to express their thoughts and concerns openly.
Correct Answer is ["B","D","E"]
Explanation
Choice A Reason:
Increasing intake of tea and coffee is incorrect. While some individuals find comfort in warm beverages like tea, excessive intake of caffeinated drinks, such as coffee, can contribute to increased anxiety and disrupted sleep. It's important to moderate caffeine consumption.
Choice B Reason:
Exercising daily for at least 20 minutes is correct. Regular exercise is a well-established stress management technique. Physical activity can help reduce stress hormones and trigger the release of endorphins, promoting a sense of well-being.
Choice C Reason:
Sleeping until late in the morning is incorrect. While adequate sleep is crucial for stress management, sleeping until late in the morning might disrupt a regular sleep schedule. Consistent and quality sleep is essential for overall well-being. Establishing a consistent sleep routine is often recommended.
Choice D Reason:
Listening to your favorite music is correct. Listening to music can have a calming effect and is often used as a relaxation technique. It can help reduce stress and improve mood.
Choice E Reason:
Receiving a good massage is correct. Massage therapy is a known stress-relieving technique. It can help relax tense muscles, reduce anxiety, and promote a sense of relaxation.
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