An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?
“The other patient started the fight.”.
“I hate all of you.”.
“My fingers are tingling.”.
“You wait until I tell my lawyer.”.
The Correct Answer is C
Choice A rationale
While it’s important to understand the circumstances leading to the assault, this statement does not require immediate attention from the nurse. It’s more related to the incident itself rather than the patient’s current condition.
Choice B rationale
Expressing hatred towards others can be a sign of emotional distress, but it does not require immediate medical attention.
Choice C rationale
Tingling in the fingers can be a sign of reduced blood circulation, which could be a result of the restraints. This requires immediate attention to prevent further complications.
Choice D rationale
While it’s important to address legal threats, this statement does not require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
The correct answer is Choice A.
When communicating with an angry patient, the nurse must first listen actively. Active listening allows the nurse to identify the key issues and work through them methodically.
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