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 A
Explanation
Choice A Reason:
Demonstrate genuineness when communicating is correct. Establishing therapeutic relationships in mental health nursing involves demonstrating genuineness, empathy, and trustworthiness in communication. Genuineness involves being authentic, sincere, and honest in interactions with clients. It fosters a sense of trust and connection, which is essential for the therapeutic relationship.
Choice B Reason:
Focusing on the words of the clients is incorrect. While it's important to listen actively to clients, effective communication goes beyond just focusing on words. Nonverbal cues, emotions, and the overall context of communication are also crucial.
Choice C Reason:
Providing sympathy during interactions is incorrect. Sympathy involves feeling sorry for someone, which may not always be helpful in a therapeutic relationship. Empathy, where the nurse understands and shares the client's feelings, is generally more therapeutic.
Choice D Reason:
Controlling the pace of establishing the nurse-client relationships is incorrect. The establishment of therapeutic relationships is a collaborative process, and attempting to control the pace might hinder the development of trust. It's important to be responsive to the client's needs and preferences.
Correct Answer is C
Explanation
Choice A Reason:
A patient who states "I have no one who cares about me. "This statement relates more to the need for belonging and love, which is a lower level on Maslow's hierarchy.
Choice B Reason:
A patient who states "I have never met my career goals." This statement relates to self-esteem and self-actualization needs, which are higher-level needs in Maslow's hierarchy.
Choice C Reason:
A patient who exhibits hostile and angry behaviors is correct. Maslow's hierarchy of needs places safety and security needs above other needs. The patient exhibiting hostile and angry behaviors may pose a threat to their own safety, the safety of others, or the overall therapeutic environment. Addressing safety concerns and de-escalating aggressive behaviors takes precedence in this situation.
Choice D Reason:
A patient upset that his family can only visit during visiting hours. This situation is related to social needs and may not be as immediate a concern as the hostile and angry behaviors described in option C.
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