A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

Wait for the client to initiate interactions with the nurse.

Set aside short, frequent times each day to spend with the client.

Disclose some personal information to the client.

Tell the client he reminds the nurse of her father.

Answer and Explanation

The Correct Answer is B

Building trust and rapport with a suspicious client takes time and consistency. By setting aside short, frequent times each day to spend with the client, the nurse demonstrates reliability, availability, and a commitment to the client's well-being. This approach allows the client to gradually develop trust and feel more comfortable interacting with the nurse.

The other options are not appropriate actions:

A. Waiting for the client to initiate interactions with the nurse may result in limited or no engagement, as the client's suspicion may hinder their willingness to reach out. It is important for the nurse to take an active role in building the therapeutic relationship.

C. Disclosing personal information to the client is not recommended. The nurse should maintain professional boundaries and focus on the client's needs and concerns rather than sharing personal details that may compromise the therapeutic relationship or create an imbalance of power.

D. Telling the client that he reminds the nurse of her father may inadvertently trigger the client's suspicious thoughts and reinforce their mistrust. Making such personal comparisons is not appropriate and can hinder the establishment of a therapeutic relationship. It is important to focus on the client's individual experiences and needs rather than making personal connections.

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Correct Answer is B

Explanation

Electroconvulsive therapy (ECT) is a procedure used to treat certain mental health conditions. When providing teaching to a client scheduled to receive ECT, it is important to provide accurate information about what they can expect during and after the procedure.

The statement "You might feel a bit confused and disoriented when you first wake up" is important because confusion and disorientation are common side effects of ECT. Clients often experience some memory loss and temporary cognitive impairment after the procedure, which can cause these symptoms. By preparing the client for these potential effects, the nurse helps reduce anxiety and ensures that the client understands what is considered normal post-ECT.

Incorrect:

A. "The most common adverse effects of ECT are related to the anesthesia." While anesthesia is used during ECT to ensure the client's comfort and safety, the most common adverse effects of ECT are related to the procedure itself, such as memory loss and cognitive changes.

C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary depending on the individual client's condition and treatment plan. It is not appropriate to provide a specific treatment schedule without knowing the client's unique circumstances.

D. "You may experience muscle cramping from the induced seizure." Muscle cramping is not a common adverse effect of ECT. The induced seizure is typically brief and controlled, and muscle relaxants are administered to prevent any excessive muscle activity during the procedure.

A. Leaving the child's room exactly as it was before the loss. B. Visiting the child's grave every week C. Talking about the child in the past tense D. Volunteering at a local children's hospital

Correct Answer is A

Explanation

Leaving the child's room exactly as it was before the loss suggests that the client is unable to accept and adapt to the reality of the child's death. This behavior can be considered maladaptive because it hinders the process of mourning and moving forward. It may reflect a difficulty in accepting the loss and adjusting to life without the child.

The other actions mentioned in the options are not necessarily indicative of maladaptive grieving:

B. Visiting the child's grave every week: Visiting the child's grave can be a normal part of the grieving process for some individuals. It provides an opportunity for the client to remember and honor the child's memory.

C. Talking about the child in the past tense: It is common for individuals to talk about a deceased loved one in the past tense. This does not necessarily indicate maladaptive grieving. It is a way of acknowledging the loss and recognizing that the person is no longer physically present.

D. Volunteering at a local children's hospital: Engaging in volunteer work can be a positive coping mechanism for individuals who have experienced a loss. It allows them to find meaning, connection, and a sense of purpose through helping others.

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A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is collecting data from a client whose child was killed 2 years ago. Which of the following actions Indicates that the client is experiencing maladaptive grieving?

Correct Answer is A

Explanation

A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make?

A nurse is caring for a client who is scheduled for electroconvulsive therapy In 1 hr. The client asks the nurse, "Can I refuse today's treatment?" Which of the following responses should the nurse make?

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

A nurse is observing a newly licensed nurse as she assists in providing family therapy for a client regarding relationship concerns with his spouse. Which of the following statements to the client by the newly licensed nurse requires intervention by the nurse?

A nurse working in a long-term care facility is admitting a client who has dementia. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.