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. "People in the mental health category of the continuum do not experience stress." B. “People can shift along various points of the mental health continuum.” C. "Most people are on some point of the mental health continuum. D. "Mental health is an important point of the mental heat continuum.

Correct Answer is A

Explanation

Choice A Reason:

"People in the mental health category of the continuum do not experience stress." This statement indicates a misunderstanding about the mental health continuum. Mental health does not imply the absence of stress; rather, it is about one's overall psychological well-being. Even individuals with good mental health may experience stress at times. The mental health continuum recognizes that people can move along different points, experiencing fluctuations in mental health based on various factors.

Choice B Reason:

“People can shift along various points of the mental health continuum. “This statement acknowledges the dynamic nature of mental health, indicating that individuals can move between different points on the continuum based on their mental well-being.

Choice C Reason:

"Most people are on some point of the mental health continuum. “This statement recognizes that mental health is a spectrum, and most individuals fall somewhere along this continuum.

Choice D Reason:

"Mental health is an important point of the mental heat continuum. “This statement reinforces the significance of mental health as a key aspect of overall well-being, which aligns with the concept of the mental health continuum.

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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

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?

Correct Answer is A

Explanation

One of the goals of a therapeutic community is for patients to become more autonomous and accept self-responsibility. Which option below best encourages fulfillment of this goal?

A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement to establish therapeutic relationships with the clients?

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

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

Which style of leadership is demonstrated when an advanced practice nurse running a group on the adolescent unit makes no attempt to control the topic or the member's behavior and makes no comment unless asked a direct question?

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?

During a therapeutic nurse-patient relationship, when would the nurse plan to first address the issue of termination?

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