The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

"Can you order the specific events that led to your admission?"

"Do you know why you are here?"

"Are you feeling depressed or anxious?"

"Yes, I see. Go on."

Answer and Explanation

The Correct Answer is D

a. "Can you order the specific events that led to your admission?" This statement directs the client to provide specific information and is more focused than a general lead. It does not encourage a broad response.
b. "Do you know why you are here?" This question is somewhat open-ended but still directs the client's response toward understanding their admission.
c. "Are you feeling depressed or anxious?" This question is specific and closed-ended, prompting a choice between two options rather than encouraging the client to freely elaborate.
d. "Yes, I see. Go on." This is correct because it encourages the client to continue speaking without directing the topic, which is the essence of a general lead.

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Correct Answer is D

Explanation

a. "I'm afraid you would feel very guilty leaving your parents." This response assumes a negative outcome and does not encourage independent decision-making.
b. "Why would you want to leave a secure home?" This response discourages the client from considering independence and reinforces dependent behavior.
c. "It would be best to do that to increase independence." This statement provides advice rather than encouraging the client to explore their own feelings and options.
d. "Let's discuss and explore all of your options." This is correct because it encourages the client to consider various possibilities and promotes independent decision-making, which is essential for someone with dependent behaviors.

A. Anticipate the behavior and restrain when pacing begins. B. Assess environmental triggers and potential unmet needs. C. Assess for potential injury. D. Consult the psychologist regarding behavior modification techniques.

Correct Answer is B

Explanation

a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.

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The nurse is interviewing a newly admitted client. Which of the following nursing statements is an example of offering a "general lead"?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client exhibiting dependent behaviors says, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate?

Correct Answer is D

Explanation

A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?

Correct Answer is B

Explanation

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