A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

Say to the interrupting patient, “I am not available to talk with you at the present time”

End the unproductive session with the current patient and spend time with the patient who has just interrupted

Invite the interrupting patient to join in the session with the current patient

Tell the patient who interrupted, “This session will be 5 more minutes; then, I will talk with you”

Answer and Explanation

The Correct Answer is D

Choice A reason: Bluntly stating unavailability dismisses the interrupting patient’s needs without offering a solution, potentially escalating distress. This approach lacks therapeutic communication, as it fails to acknowledge the patient’s urgency or provide a clear plan, which is critical in maintaining trust in a mental health setting.

Choice B reason: Ending the current session prematurely disrespects the silent patient’s therapeutic process. Silence may reflect processing or discomfort, requiring time to build trust. Abruptly shifting focus undermines the current patient’s care, potentially worsening their mental health and disrupting the therapeutic relationship.

Choice C reason: Inviting the interrupting patient to join violates confidentiality and disrupts the current patient’s safe space. Combining sessions without consent breaches ethical principles, potentially causing discomfort or mistrust, which hinders therapeutic progress for both patients in a mental health context.

Choice D reason: Acknowledging the interruption and scheduling a follow-up in 5 minutes respects both patients’ needs. It maintains the current patient’s therapeutic time while addressing the interrupting patient’s urgency, ensuring fairness and trust. This approach upholds ethical care and supports a therapeutic environment for mental health treatment.

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Correct Answer is C

Explanation

Choice A reason: Allowing a client with suicidal comments to leave against medical advice is unsafe, as it risks self-harm without immediate intervention. Providing resources does not address acute suicide risk, which requires inpatient stabilization to ensure safety, making this action inappropriate in the context of expressed suicidal ideation.

Choice B reason: Contacting family to persuade the client to stay does not address immediate suicide risk. While family support may be helpful, it lacks legal authority to prevent discharge and does not ensure safety, making it less effective than initiating a commitment for a client with suicidal intent.

Choice C reason: A 302 involuntary commitment is appropriate for a client expressing suicidal ideation, indicating imminent danger to self. This legal action ensures safety through inpatient evaluation and treatment, preventing self-harm. Mental health laws prioritize protection in such cases, making this the most appropriate nursing action.

Choice D reason: Calling security to detain the client is coercive and lacks legal basis without a formal commitment process. It may escalate agitation and violate autonomy. A 302 commitment is the proper legal mechanism to ensure safety for a suicidal client, making detention by security inappropriate.

A. Since ours is a professional relationship, let’s explore other opportunities in your life for friendship B. We are definitely not friends; this is strictly professional C. I am sure there are other people in your life who are your friends; besides, we just met D. It makes me feel good that you see me as a friend; it is important for the work we are doing together

Correct Answer is A

Explanation

Choice A reason: This response reinforces professional boundaries while therapeutically redirecting the client to explore external social support, addressing potential dependency. It validates the client’s feelings without personalizing the relationship, promoting healthy coping and social integration, which are critical for mental health recovery and maintaining therapeutic integrity.

Choice B reason: Bluntly denying friendship dismisses the client’s feelings, potentially damaging trust and therapeutic rapport. This approach risks alienating the client, who may feel rejected, hindering open communication and progress in addressing underlying emotional needs, making it non-therapeutic in a mental health context.

Choice C reason: Suggesting other friends without exploration dismisses the client’s expressed feelings, potentially invalidating their emotional experience. The assumption about existing friends may not apply, and the response lacks therapeutic engagement, failing to address the client’s dependency or need for social connection, making it less effective.

Choice D reason: Affirming the client’s view of friendship blurs professional boundaries, fostering dependency and compromising therapeutic objectivity. While validating feelings is important, reinforcing a personal connection risks hindering the client’s ability to develop external support systems, making this response non-therapeutic for mental health progress.

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A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

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Correct Answer is C

Explanation

A nurse and client are engaged in a discussion. The client says, “I feel really close to you. You are my only true friend.” Which response by the nurse would be most therapeutic?

Correct Answer is A

Explanation

The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, “What if I encounter a client who is sexually aggressive?” Which is the appropriate response by the preceptor?

The nurse is receiving the morning report on four clients on a medical-surgical unit. Based on the information provided, which clients are at greatest risk for developing end-stage renal disease (ESRD)? (Select all that apply)