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 ["3.5"]
Explanation
He has been prescribed Fluphenazine decanoate 87.5 mg intramuscularly every 3 weeks to treat his schizophrenia. The nurse checks the medication order and the vial label. The vial contains Fluphenazine decanoate 25 mg per milliliter. To calculate the amount of medication to administer, the nurse uses the formula:
dose ordered / dose available = mL to administer
Substituting the values, the nurse gets:
87.5 mg / 25 mg/ml = 3.5 ml
Therefore, the nurse will administer 3.5 milliliters of Fluphenazine decanoate for this dose.
Correct Answer is A
Explanation
Choice A Reason:
Technical expert is correct. In Peplau's Interpersonal Relations in Nursing theory, the emphasis is on the interpersonal and psychosocial aspects of nursing. While technical expertise is crucial in nursing practice, it is not specifically identified as a distinct role according to Peplau. The theory focuses more on the nurse's role in facilitating the patient's growth and development through the therapeutic relationship.
Choice B Reason:
Resource is incorrect. Peplau identified the nurse as a resource, emphasizing the nurse's role in providing information, support, and guidance to the patient. This aligns with the concept of the nurse as a source of knowledge and assistance for the patient.
Choice C Reason:
Surrogate is incorrect. The surrogate role in Peplau's theory reflects the nurse's ability to act on behalf of the patient, representing their best interests, especially in situations where the patient may be unable to advocate for themselves. The nurse serves as a substitute or stand-in for the patient in certain circumstances.
Choice D Reason:
Guardian is incorrect. The guardian role in Peplau's theory emphasizes the nurse's responsibility to protect the patient's rights and advocate for their well-being. The nurse acts as a guardian of the patient's interests, ensuring they receive appropriate care and support.
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