A nurse is caring for a patient hospitalized for the treatment of severe depression. Which of the following nursing approaches should be included in the patient’s care plan?
Spend time sitting with the patient.
Offer the patient choices of activities.
Establish a patient relationship.
Explore the truth of the patient’s statements.
The Correct Answer is A
Choice A rationale
Spending time with the patient is a therapeutic nursing approach when caring for a patient hospitalized for the treatment of severe depression. This approach shows the patient that they
are not alone and that their feelings are important. It can help build trust and rapport, which are essential for effective therapeutic communication and intervention.
Choice B rationale
Offering the patient choices of activities can be beneficial as it can provide a sense of control and improve mood. However, this approach should be used judiciously as the patient’s energy levels and interest in activities may be low due to depression.
Choice C rationale
Establishing a therapeutic relationship with the patient is an important aspect of care. However, this is a broad approach and involves more than just spending time with the patient. It includes building trust, maintaining confidentiality, and providing empathetic and nonjudgmental care.
Choice D rationale
Exploring the truth of the patient’s statements can be part of cognitive behavioral therapy (CBT), a common treatment for depression. However, this is usually done by a trained therapist and not by a nurse providing general care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Lifting a patient under the shoulders by two nurses can be strenuous and may not provide adequate support for a patient who can only partially assist.
Choice B rationale
While this method may work for some patients, it relies heavily on the patient’s strength and ability to push with their feet. If the patient is weak or unable to exert enough force, this method could be unsafe.
Choice C rationale
Using a device to reduce friction is the most appropriate technique when shifting a patient who can only partially assist. Devices such as slide sheets or transfer boards can help move the patient smoothly and with less physical strain on the healthcare provider.
Choice D rationale
Lifting the patient’s legs while the patient uses a trapeze bar requires significant upper body strength from the patient and may not be feasible for all patients.
Correct Answer is A
Explanation
Choice A rationale
Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying
tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.
Choice B rationale
Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.
Choice C rationale
Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.
Choice D rationale
Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.
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