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The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
- A. Tell me what you think should happen.
- B. How serious was the collision?
- C. What do you think you should do?
- D. Call for transportation to the hospital.
Correct Answer: D
Rationale: The correct response is D: Call for transportation to the hospital. In this crisis situation, the most urgent need is for the employee to be with her child at the hospital. By providing transportation, the nurse ensures that the employee can reach her child quickly and offer support. This action demonstrates empathy and prioritizes the employee's immediate needs.
A: Asking the employee what she thinks should happen may not be the most appropriate response in a crisis where decisive action is needed.
B: Inquiring about the seriousness of the collision is secondary to ensuring the employee can reach her child at the hospital.
C: Asking the employee what she thinks she should do puts the onus on her to make a decision when she may be in distress and unable to think clearly.
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The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?
- A. Establishing a rapport with group members.
- B. Clarifying the nurse’s role and clients’ responsibilities.
- C. Discussing ways to use new coping skills learned.
- D. Helping clients identify areas of problem in their lives.
Correct Answer: C
Rationale: The correct answer is C: Discussing ways to use new coping skills learned. During the working phase of group development, the focus is on implementing and practicing new skills and strategies. This helps group members apply what they have learned to their real-life situations. By discussing ways to use new coping skills, the RN is facilitating the group's progress towards achieving their therapeutic goals.
A: Establishing a rapport with group members is important in the initial phase of group development, not during the working phase.
B: Clarifying the nurse’s role and clients’ responsibilities is more relevant to the orientation phase, not the working phase.
D: Helping clients identify areas of problem in their lives is typically done in the initial assessment phase, not during the working phase.
James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for day shift and anxiously reports, “Last night, demons came to my room and tried to rape me.†Which response would be most therapeutic?
- A. There are no such things as demons. What you saw were hallucinations.
- B. It is not possible for anyone to enter your room at night. You are safe here.
- C. You seem very upset. Please tell me more about what you experienced last night.
- D. That must have been very frightening, but we’ll check on you at night and you’ll be safe.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and active listening. By acknowledging James's feelings and inviting him to share more about his experience, the response validates his emotions and fosters trust. This approach helps build a therapeutic relationship and allows for a deeper exploration of his hallucinations. Options A and B invalidate James's experience and may increase his distress. Option D offers reassurance but lacks the immediate emotional support James needs.
Which nursing statement is an example of reflection?
- A. I think this feeling will pass.
- B. So you are saying that life has no meaning.
- C. I’m not sure I understand what you mean.
- D. You look sad.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates reflective listening by paraphrasing and summarizing the patient's statement. This shows active listening and understanding of the patient's perspective. Choice A is about personal feelings, not reflecting the patient's emotions. Choice C is a statement of uncertainty, not reflective listening. Choice D is an observation, not reflection.
During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
- A. Assist the client in developing alternative coping skills.
- B. Remain calm and use a matter of fact approach.
- C. Ask the client why she is so anxious
- D. Administer a PRN sedative to help relieve her anxiety.
Correct Answer: B
Rationale: The correct answer is B: Remain calm and use a matter-of-fact approach. This approach is essential to provide a sense of safety and security for the client experiencing extreme anxiety. By remaining calm, the nurse can model a calming presence and help the client feel more at ease. Using a matter-of-fact approach can help normalize the situation and reassure the client that her feelings are valid but manageable.
A: Assisting the client in developing coping skills may be beneficial in the long term, but in this acute situation, the immediate focus should be on providing immediate support.
C: Asking the client why she is anxious may not be helpful as it can potentially increase her anxiety or lead to a delusional explanation.
D: Administering a sedative should not be the first intervention as it does not address the underlying cause of the anxiety and may mask important information that could help in providing appropriate care.
In summary, the most important intervention is remaining calm and using a matter-of-fact
During an admission assessment and interview, which channels of information communication should the nurse be monitoring? Select all that apply.
- A. Auditory
- B. Visual
- C. Written
- D. Tactile
Correct Answer: A
Rationale: The correct answer is A: Auditory. During an admission assessment and interview, monitoring auditory communication channels is crucial for gathering information through spoken words, tone, and non-verbal cues like sighs or hesitations. This helps the nurse assess the patient's mental state, emotions, and communication effectiveness. Visual (B), written (C), and tactile (D) channels are not typically monitored during a standard interview, as they may not provide relevant information for the assessment process. Visual cues like body language can be important but are not as essential as auditory cues in this context. Written communication is not typically used in a face-to-face interview, and tactile communication is usually unnecessary unless specific procedures are being performed.