A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?
"You should try to see your partner's point of view before your own.”
"Relationship difficulties are stressful and require effort to resolve.”
"We could develop a plan for how to talk about this with your partner.”
"Tell me more about the concerns that you have regarding your marriage.”
The Correct Answer is A
Choice A rationale:
This statement requires intervention by the charge nurse. The nurse is making a judgmental suggestion to the client about how they should approach their marital issues. The nurse's role is to provide support, empathy, and open-ended questions that allow the client to explore their feelings and thoughts. Making a directive statement like this can be perceived as controlling and dismissive of the client's feelings.
Choice B rationale:
Relationship difficulties being stressful and requiring effort to resolve is an appropriate and empathetic response from the nurse. This acknowledges the client's struggles and offers validation without imposing a particular solution.
Choice C rationale:
Developing a plan for communication is a constructive approach that helps the client address their concerns. This response is within the nurse's scope of practice and promotes problem-solving and effective communication between partners.
Choice D rationale:
Encouraging the client to share more about their concerns regarding their marriage is a therapeutic response. It shows active listening and facilitates the client's exploration of their feelings, which is an essential aspect of the nursing role in a therapeutic relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. A room containing personal belongings.
Choice A rationale:
A room without a window would likely be isolating and could contribute to feelings of confusion and disorientation in a cognitively impaired individual. Natural light from windows helps regulate the circadian rhythm and provides a sense of time, which is crucial for maintaining a therapeutic environment.
Choice B rationale:
A room containing personal belongings is the correct choice. Familiar items from home can provide comfort and a sense of familiarity, reducing anxiety and agitation in cognitively impaired individuals. These belongings can act as cues for memory recall and assist in maintaining a connection to their personal identity.
Choice C rationale:
A room adjacent to the nursing station might lead to increased noise and disruption for the client. Cognitively impaired individuals often benefit from a quiet and calm environment, which would not be ensured in a room close to a potentially busy nursing station.
Choice D rationale:
A room with dim lighting can exacerbate confusion and disorientation in cognitively impaired individuals. Adequate lighting is essential for maintaining a safe and structured environment, as poor lighting can lead to falls and increased disorientation.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.
Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.
Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.
Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.
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