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?

"I will assist you in getting out of bed and getting dressed."

"You can remain in bed until you feel well enough to join the milieu."

"The unit rules state that clients may not remain in bed."

"If you don't participate in your care, you will not get better."

Answer and Explanation

The Correct Answer is A

The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.

The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.

The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.

The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.

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Correct Answer is A

Explanation

Memory loss is a known side effect of electroconvulsive therapy (ECT), particularly in the short term. It is important for the nurse to provide accurate information to the client about this

potential side effect. Assuring the client that memory loss is common and tends to improve over time can help alleviate their concerns and provide reassurance. It is important to convey that this is a temporary effect and not necessarily indicative of long-term memory problems.

The other options are not appropriate responses:

B. "You will likely experience long-term memory loss as well": This statement provides inaccurate and potentially alarming information. While some individuals may experience persistent memory issues, it is not appropriate to assume or predict long-term memory loss in every case.

C. "You should focus on how much better you feel": This response dismisses the client's concerns about memory loss and may not address their needs or worries adequately. It is important to acknowledge and validate the client's experience.

D. "I am going to notify your provider about your memory loss": While it is important for the nurse to communicate any concerning symptoms to the client's healthcare provider, simply stating this without providing further information or reassurance may increase the client's anxiety without addressing their immediate concerns about memory loss.

A. Orientation to reality B. Remotivation C. Validation D. Guided imagery

Correct Answer is C

Explanation

Validation is a technique used to acknowledge and validate the emotions and experiences of individuals with dementia, even if their thoughts or perceptions do not align with reality. In this scenario, the nurse responds by saying, "You miss your mother," which shows understanding and empathy toward the client's emotions. The nurse is validating the client's feelings rather than attempting to correct or redirect their thoughts.

A. Orientation to reality involves providing factual information and attempting to reorient individuals with dementia to the present time, place, and situation.

B. Remotivation is a technique used to stimulate memories and engage individuals with dementia in meaningful activities.

D. Guided imagery involves using vivid language and descriptive prompts to guide individuals into imagining pleasant or calming scenes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has received nine electroconvulsive therapy (ECT) treatments and reports short-term memory loss. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

Correct Answer is C

Explanation

A nurse is caring for a client who reports a state of Increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement?

A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding?

A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?