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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

Facing reality and developing standards for responsible behavior is inappropriate. This goal aligns more with reality therapy or choice theory, which focuses on helping individuals take responsibility for their behavior and make choices that lead to responsible actions.

Choice B Reason:

Examining irrational beliefs and eliminating self-defeating behaviors is appropriate. Beck's cognitive-behavioral therapy (CBT) is based on the premise that thoughts influence feelings and behaviors. The goal of CBT is to identify and change irrational or distorted thoughts that contribute to negative emotions and behaviors. This process involves examining irrational beliefs and challenging cognitive distortions to promote more realistic and adaptive thinking.

Choice C Reason:

Developing satisfactory relationships, maturity, and relative freedom from anxiety is inappropriate. This goal may align with psychodynamic or humanistic approaches that emphasize personal growth, self-awareness, and improvement in relationships.

Choice D Reason:

Reducing body tension through biofeedback training is inappropriate. This goal is more aligned with behavioral approaches that use techniques like biofeedback to address physiological symptoms.

A. Diffuse B. Clear C. Differentiation D. Rigid

Correct Answer is A

Explanation

Choice A Reason:

Diffuse is correct. In a diffuse or permeable family boundary, there is a lack of clear separation between family members. Decisions and responsibilities may be shared extensively, and individual autonomy is limited. The patient's behavior of consulting with family members before making treatment decisions suggests a diffuse boundary where decision-making involves significant input from various family members.

Choice B Reason:

Clear is incorrect. - In a clear or rigid boundary, there is a distinct separation between family members, and individual autonomy is highly emphasized. The described behavior does not align with a clear boundary.

Choice C Reason:

Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. The behavior described is more indicative of a diffuse boundary than a differentiation issue.

Choice D Reason:

Rigid is incorrect. A rigid boundary is characterized by strict rules and limited flexibility. The described behavior does not align with a rigid boundary where decision-making might be more centralized and less consultative.

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Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which goal represents Beck's cognitive-behavioral model?

Correct Answer is B

Explanation

The nurse is caring for a patient who consults with family members before making every treatment decision. Based on the nurse's observation. which type of boundary exists within the family structure?

Correct Answer is A

Explanation

Which of the following is not a nursing role according to Peplau?

Which action would the nurse include when beginning a relationship with a new patient? Select all that apply. (Select All that Apply.)

The nurse can best communicate to a patient that she has been listening by:

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says. "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)

The nurse is educating a patient with depression about the mental health continuum. Which statement made by the patient indicates the need for additional teaching?

Which patient statement best captures the helpfulness of the nurse-patient relationship? Select one: