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The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention should be included in the nursing care plan?
- A. Placing the client in a private room to ensure privacy and confidentiality
- B. Interacting with the client demonstrating examples of unconditional positive regard
- C. Maintaining a distance of 10 inches in order to ensure the client that personal control will be provided
- D. Placing the client in charge of a meaningful unit activity, such as the morning chess tournament
Correct Answer: B
Rationale: The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and the client's thinking are unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. The client would not be placed in a private room because this is an unsafe action that may intensify the client's feelings of worthlessness. Distance of 18 inches or less between two individuals constitutes intimate space. The invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness. Placing the client in charge of the morning chess tournament is a premature intervention that can overwhelm the client and cause the client to fail; this can reinforce the client's feelings of worthlessness.
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A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time?
- A. Remaining with the client
- B. Placing the client in a quiet room
- C. Teaching the client deep-breathing exercises
- D. Encouraging the expression of feelings and concerns
Correct Answer: A
Rationale: If the client is left alone with severe anxiety, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
The nurse has an established relationship with the family of a client whose death is imminent. Which intervention should the nurse focus on in order to help the family most effectively cope with this experience?
- A. Limiting time in the client's room to promote privacy
- B. Providing education regarding coping mechanisms to use
- C. Identifying spiritual measures that work best for dying clients
- D. Answering questions clearly and providing resources as requested
Correct Answer: D
Rationale: Maintaining effective and open communication among family members affected by death and grief is important to facilitate decision making and effective coping. The nurse maintains and enhances communication and preserves the family's sense of self-direction and control effectively by answering questions clearly and providing information and resources for decision making as requested by the family. Isolating the family from the client by limiting time in the client's room is inappropriate. The nurse should not provide education about coping mechanisms for family members to use because coping mechanisms directed by the nurse are unlikely to be as effective as the methods that the individuals choose for themselves. Identifying spiritual measures that work best for the dying client generalizes and does not reflect individualized care.
The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, 'If this is a stroke, it's the kiss of death.' What initial response should the nurse make?
- A. Why would you think like that?'
- B. You feel your mother is dying?'
- C. These symptoms are reversible.'
- D. A stroke is not the kiss of death.'
Correct Answer: B
Rationale: Option 2 allows the daughter to verbalize her feelings, begin coping, and adapt to what is happening. By restating, the nurse seeks clarification of the daughter's feelings and offers information that potentially helps ease some of the fears and concerns related to the client's condition and prognosis. Option 1 is a disapproving comment that is likely to interfere with communication. Option 3 is potentially misleading and offers false hope. The nurse could reflect back the statement in option 4 to the daughter to promote communication. However, as it stands, option 4 is a barrier to communication that contradicts the daughter's feelings.
A client diagnosed with Parkinson's disease is having difficulty adjusting to the disorder. The nurse provides education to the family that focuses on addressing the client's activities of daily living. Which statement indicates that the teaching has been effective?
- A. We should plan for only a few activities during the day.'
- B. We should assist with activities of daily living as much as possible.'
- C. We should cluster activities at the end of the day, to help conserve energy.'
- D. We should encourage and praise efforts to exercise and perform activities of daily living.'
Correct Answer: D
Rationale: The client with Parkinson's disease has a tendency to become withdrawn and depressed, which can be limited by encouraging the client to be an active participant in his or her own care. The family should plan activities intermittently throughout the day to inhibit daytime sleeping and boredom. The family should also give the client encouragement and praise for his or her perseverance in these efforts and help only when necessary.
A community health nurse is caring for a group of homeless people. What is the most immediate concern when planning for the potential needs of this group?
- A. Finding affordable housing for the group
- B. Setting up a 24-hour crisis center and hotline
- C. Providing peer support through structured support groups
- D. Ensuring that adequate food, shelter, and clothing are available
Correct Answer: D
Rationale: The question asks about the situation's most immediate concern. The initial community health concern is always attending to people's basic physiological needs of food, shelter, and clothing. Finding affordable housing and providing crisis intervention and peer support are meaningful interventions that may be completed at a later time.