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 C

Explanation

Choice A Reason:

"Your husband is making really good progress" This statement assumes a positive or negative judgment about the husband's progress without first understanding the spouse's concerns. It may not address the spouse's immediate emotional needs or allow them to express their feelings.

Choice B Reason:

"Crying helps us let things out and we feel better". While this statement acknowledges the act of crying as a way to express emotions, it doesn't directly address the specific concerns of the spouse or invite further communication about the issues causing distress.

Choice C Reason:

"Tell me what is concerning you. “This is a therapeutic nursing response because it encourages the spouse to express their concerns and share their feelings. It opens up communication and allows the nurse to better understand the specific issues or worries that the spouse is experiencing. This response demonstrates active listening and a genuine interest in the spouse's perspective, fostering a supportive and empathetic therapeutic relationship.

Choice D Reason:

"Did your husband say something to upset you?" This question assumes that the spouse's distress is solely related to something the husband said. It may not be the most open-ended or empathetic way to encourage the spouse to share their concerns and might direct the focus too narrowly.

A. Have too far from art and history museums to visit them as often as I would like B. Four robberies and three assault to occurred in my neighborhood in the past month C. Feel so alone. I wish had someone special in my life. D. Did not do a good job on the project may supersker assigned

Correct Answer is B

Explanation

Choice A Reason:

“I live too far from art and history museums to visit them as often as I would like. “This pertains more to self-actualization and leisure activities, which are higher-level needs.

Choice B Reason:

"Four robberies and three assaults occurred in my neighborhood in the past month. “This statement addresses safety concerns, which fall under the second level of Maslow's hierarchy. Ensuring safety is a fundamental need that takes priority before addressing social or esteem needs.

Choice C Reason:

"I feel so alone. I wish I had someone special in my life." This addresses the need for belonging and social connection, which is a higher-level need compared to safety.

Choice D Reason:

"I did not do a good job on the project my supervisor assigned." This relates to self-esteem and job performance, which are higher-level needs.

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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

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?

Correct Answer is C

Explanation

Using Maslow's pyramid, which patient comment would the nurse respond to first?

Correct Answer is B

Explanation

Which activity would happen first in the nurse-patient relationship?

Which statement suggests a struggle with Erikson's phase of Identity vs. role confusion? Select one:

Peplau's Interpersonal Theory of Nursing: Select one:

A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client asks which birth control method the nurse would recommend. Which of the following responses should the nurse make?

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?

According to Maslow's hierarchy of needs, which situation on an inpatient mental health unit would require priority intervention?

Which intervention would the nurse suggest to a patient seeking advice regarding stress management? Select all that apply.

Which activity would a nurse perform in an inpatient psychiatric unit? Select all that apply. (Select All that Apply.)