A nurse enters the community room of an acute mental health unit and observes a client yelling at another client. Which of the following statements should the nurse make to the client?

"Your behavior will be disappointing to your provider."

"I'm taking away your privileges for the rest of the week."

"yelling at others is unacceptable."

"Why did you hit another client?"

Answer and Explanation

The Correct Answer is C

A. "Your behavior will be disappointing to your provider." This statement is not helpful because it focuses on the feelings of the provider rather than addressing the behavior itself or its consequences for the client.
B. "I'm taking away your privileges for the rest of the week." This is a punitive response and does not address the immediate issue of the client's behavior. It is more important to address the behavior and its impact rather than imposing a punishment.
C. "Yelling at others is unacceptable." This statement directly addresses the behavior and sets a clear boundary. It is an appropriate way to communicate that the behavior is not acceptable.
D. "Why did you hit another client?" This question assumes the client hit another client, which might not be accurate and can escalate the situation. It’s better to address the observed behavior directly.

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Correct Answer is A

Explanation

A. Transference: Transference occurs when a client projects feelings about someone from their past onto the therapist or nurse. The client’s feelings about the nurse being similar to their mother fit this description.
B. Confrontation: Confrontation involves addressing discrepancies or issues directly, which is not the focus here. The situation described is about the client’s feelings towards the nurse.
C. Countertransference: Countertransference occurs when a nurse or therapist has emotional reactions based on their own past experiences, not the client’s feelings about the nurse.
D. Incongruence: Incongruence refers to a mismatch between a person's experiences and their self-concept. The situation described involves the client's feelings toward the nurse rather than incongruence.

A. Oriented to time, place and personal hygiene B. Alert and oriented to person, place and time C. Anxious, alert and oriented to place D. Awake and oriented to place

Correct Answer is B

Explanation

A. Oriented to time, place and personal hygiene: This is incorrect. Orientation X3 refers to being oriented to person, place, and time, not personal hygiene.
B. Alert and oriented to person, place and time: This is correct. "Oriented X3" means that the client is aware of who they are (person), where they are (place), and what time it is (time).
C. Anxious, alert and oriented to place: This is incorrect. Orientation X3 does not specifically address anxiety or focus solely on orientation to place.
D. Awake and oriented to place: This is incorrect. Orientation X3 includes person, place, and time, not just being awake and oriented to place.

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A nurse enters the community room of an acute mental health unit and observes a client yelling at another client. Which of the following statements should the nurse make to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute mental health center is performing a physical assessment on a client. Which of the following findings should the nurse document under the integumentary system? (Select all that apply.)

Correct Answer is A

Explanation

During a psychosocial assessment, the nurse documents a patient's orientation as oriented X3. This means:

Correct Answer is B

Explanation

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