A patient is pacing the hall near the nurse’s station, swearing loudly. What would be an appropriate initial intervention for the nurse?

Please be quiet and sit down in this chair immediately.

I’d like to talk with you about how you’re feeling right now.

You must go to your room and try to control yourself.

What is going on?

Answer and Explanation

The Correct Answer is B

Choice A rationale
Telling the patient to be quiet and sit down immediately may seem like a quick solution, but it is not the most therapeutic response. This approach may come across as dismissive and authoritarian, which could escalate the patient’s agitation.
Choice B rationale
This is the most appropriate initial intervention. By expressing a desire to understand the patient’s feelings, the nurse opens up a line of communication and shows empathy. This can help de-escalate the situation and make the patient feel heard and understood.
Choice C rationale
Telling the patient to go to their room and control themselves can come across as dismissive and invalidating. It does not address the patient’s feelings or concerns and may escalate the situation.
Choice D rationale
Asking “What is going on?” is a good way to encourage the patient to express their feelings, but it may not be as effective as Choice B. The phrasing in Choice B is more direct and shows more empathy and concern for the patient’s emotional state.

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Correct Answer is A

Explanation

Choice A rationale
The nurse’s response, “Tell me how you felt when your fiancé broke up with you,” is the most therapeutic because it encourages the client to express feelings. This is a crucial step in the healing process. The nurse is using active listening skills and showing empathy, which can help build a therapeutic relationship with the client. It’s important for the nurse to provide a safe and nonjudgmental environment for the client to express feelings of sadness, anger, or guilt related to the breakup.
Choice B rationale
The response, “Maybe the breakup was for the best,” is not therapeutic because it minimizes the client’s feelings and experiences. It’s not the nurse’s place to make judgments or assumptions about the situation. The nurse should focus on the client’s feelings and provide support.
Choice C rationale
The response, “Do you think you are better off without your fiancé?” could be seen as leading or suggestive. It’s important for the nurse to remain neutral and not impose personal beliefs or opinions on the client.
Choice D rationale
The response, “How could your fiancé be wonderful after saying those things to you?” could be seen as confrontational and judgmental. It’s not the nurse’s role to judge the client’s relationships or experiences. The nurse should provide a supportive and understanding environment for the client to express feelings.

A. Monitor mental status. B. Encourage the individual to recall recent events. C. Assess vital signs. D. Contact family members.

Correct Answer is C

Explanation

Choice A rationale
Monitoring mental status is important, but it is not the priority nursing action in this situation. The individual has been found after being missing for 48 hours and the immediate concern should be their physical well-being.
Choice B rationale
Encouraging the individual to recall recent events may be part of the assessment process, but it is not the priority nursing action. The individual’s physical health could be at risk after being outside for an extended period, and this should be addressed first.
Choice C rationale
Assessing vital signs is the priority nursing action. The individual has been found after being missing for 48 hours, potentially exposed to harsh weather conditions and without access to food or water. It is crucial to assess their physical state as they may be dehydrated, hypothermic, or have other immediate health concerns.
Choice D rationale
Contacting family members is important for providing information and support, but it is not the priority nursing action. The first concern should be to assess and stabilize the individual’s physical condition.

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A patient is pacing the hall near the nurse’s station, swearing loudly. What would be an appropriate initial intervention for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

During the assessment phase of the nursing process, data collection takes place. What methods does the nurse employ to gather data? (Select all that apply.)

What are the goals of therapeutic communication?

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