During a psychosocial assessment, the nurse documents a patient's orientation as oriented X3. This means:
Oriented to time, place and personal hygiene
Alert and oriented to person, place and time
Anxious, alert and oriented to place
Awake and oriented to place
The Correct Answer is B
A. Oriented to time, place and personal hygiene: This is incorrect. Orientation X3 refers to being oriented to person, place, and time, not personal hygiene.
B. Alert and oriented to person, place and time: This is correct. "Oriented X3" means that the client is aware of who they are (person), where they are (place), and what time it is (time).
C. Anxious, alert and oriented to place: This is incorrect. Orientation X3 does not specifically address anxiety or focus solely on orientation to place.
D. Awake and oriented to place: This is incorrect. Orientation X3 includes person, place, and time, not just being awake and oriented to place.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "If you don't participate in your care, you will not get better." This statement is not therapeutic as it may be perceived as judgmental or coercive. It could further discourage the client, especially if they are struggling with motivation due to depression.
B. "You can remain in bed until you feel well enough to join the group." While this response shows empathy, it might inadvertently reinforce the client's avoidance behavior and contribute to further isolation. It is generally more beneficial to encourage gradual participation rather than allowing complete withdrawal.
C. "I will assist you in getting out of bed and getting dressed." This option is appropriate because it offers support and encouragement in a gentle, non-coercive manner. Assisting the client in small steps can help them overcome inertia and begin to participate more actively in their care.
D. "The unit rules state that clients may not remain in bed." This approach is likely to be perceived as rigid and punitive. It does not address the client’s emotional state or offer support, which is crucial for someone struggling with depression.
Correct Answer is C
Explanation
A. "Why do you think your father chose that time and place to yell at you?" This question might come across as blaming or accusatory, potentially making the client defensive.
B. "Well it sounds like your father has difficulty controlling his temper." This statement focuses on the father's behavior rather than the client's feelings, which isn't empathetic.
C. "You must have been embarrassed when your father yelled at you in the grocery store." This response acknowledges and validates the client's feelings, demonstrating empathy.
D. "You really should find your own housing and get out of the situation with your father." This advice-giving response might seem insensitive to the client's current situation and lacks empathy.
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