A nurse is caring for a client who states, "I don’t belong here." Which response is most appropriate?

Were you feeling this way before this hospitalization?

You don’t think this is the right place for your care?

Suggest you discuss your concerns with the doctor in the morning

This is an inappropriate statement for you to make

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking if the client felt this way before hospitalization focuses on past feelings, which may not address the current emotional state or therapeutic needs. While it gathers history, it lacks empathy and does not encourage the client to elaborate on their current concerns, making it less therapeutic.

Choice B reason: Reflecting the client’s statement by asking if they feel the setting is wrong demonstrates active listening and empathy, key components of therapeutic communication. It encourages the client to express feelings, fostering trust and exploration of their concerns, aligning with psychiatric nursing principles, making this the correct choice.

Choice C reason: Suggesting the client discuss concerns later with a doctor dismisses their current emotional state, potentially undermining trust in the nurse-client relationship. It avoids immediate engagement and fails to address the client’s feelings, which is critical in psychiatric care, making this response non-therapeutic and incorrect.

Choice D reason: Labeling the client’s statement as inappropriate is judgmental and dismissive, hindering therapeutic communication. It may increase the client’s sense of alienation or shame, contrary to psychiatric nursing goals of building trust and validating feelings. This response is non-therapeutic and does not support the client’s emotional needs.

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Correct Answer is B

Explanation

Choice A reason: A provider giving a telephone order is a standard practice in healthcare, not inherently requiring reporting unless the order is unsafe. It does not indicate negligence or ethical violations, unlike impaired practice or boundary issues, making it incorrect for mandatory intervention and reporting.

Choice B reason: A peer under the influence of alcohol compromises patient safety due to impaired judgment and coordination, a serious ethical and professional violation. Nurses are obligated to report such behavior to protect patients, aligning with nursing ethics and safety protocols, making this a correct choice.

Choice C reason: Violating relationship boundaries with a patient, such as inappropriate personal interactions, breaches ethical standards and risks patient harm. Nurses must report this to ensure patient safety and maintain professional integrity, aligning with mental health care ethics, making this a correct choice.

Choice D reason: A licensed provider prescribing medication is a routine clinical action, not requiring reporting unless the prescription is unsafe or inappropriate. This choice does not inherently indicate a need for intervention, unlike impaired practice or boundary violations, making it incorrect.

A. Arrange for social services to address the patient’s housing needs B. Contact the landlord to discuss the eviction situation further C. Determine whether the adverse medication reaction was genuine D. Delay discharge until the patient’s mental status improves

Correct Answer is A

Explanation

Choice A reason: Arranging social services addresses the patient’s eviction, a social determinant of health impacting mental stability. This holistic approach supports recovery by ensuring housing stability, aligning with psychiatric nursing’s focus on comprehensive care, making this the correct choice.

Choice B reason: Contacting the landlord directly exceeds the nurse’s role and may violate privacy. It does not address the patient’s immediate housing needs or mental health, making it less appropriate than coordinating with social services for professional support.

Choice C reason: Questioning the medication reaction’s validity is inappropriate without evidence and distracts from addressing the eviction. It undermines trust and does not support discharge planning, making this choice irrelevant to the patient’s current needs.

Choice D reason: Delaying discharge without clinical justification risks unnecessary hospitalization. The eviction requires social support, not prolonged admission, as mental status improvement is not specified as a concern, making this choice incorrect.

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A nurse is caring for a client who states, "I don’t belong here." Which response is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which situations would a nurse have the duty to intervene and report? (Select all that apply)

Correct Answer is B

Explanation

A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the nurse learned the patient received a notice of eviction immediately prior to admission. Select the nurse’s most appropriate action.

Correct Answer is A

Explanation

Which comment indicates the patient perceived the nurse was caring?

A nurse uses Maslow's hierarchy of needs to plan care for a patient diagnosed with mental illness. Which problem will receive priority?

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