Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?

Building a trusting relationship

Searching her belongings

Orienting her to the unit

Helping her settle into her room

Answer and Explanation

The Correct Answer is B

A. Building a trusting relationship: Establishing trust is essential in therapeutic relationships, especially with clients at risk for self-harm. However, ensuring the client’s immediate safety by searching belongings takes precedence to protect the client from further harm.

B. Searching her belongings: This is the first priority to ensure Patty’s immediate safety and prevent access to any objects she could use to harm herself. This action addresses the immediate risk and creates a safer environment for her.

C. Orienting her to the unit. Orientation to the unit helps the client feel more comfortable and understand the rules and layout of the facility, but it is not as urgent as ensuring her safety upon admission.

D. Helping her settle into her room: Assisting Patty in getting comfortable is important for her overall well-being but is secondary to securing her environment by removing any potentially harmful items.

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Correct Answer is C

Explanation

Choice A Reason:

A patient who states "I have no one who cares about me. "This statement relates more to the need for belonging and love, which is a lower level on Maslow's hierarchy.

Choice B Reason:

A patient who states "I have never met my career goals." This statement relates to self-esteem and self-actualization needs, which are higher-level needs in Maslow's hierarchy.

Choice C Reason:

A patient who exhibits hostile and angry behaviors is correct. Maslow's hierarchy of needs places safety and security needs above other needs. The patient exhibiting hostile and angry behaviors may pose a threat to their own safety, the safety of others, or the overall therapeutic environment. Addressing safety concerns and de-escalating aggressive behaviors takes precedence in this situation.

Choice D Reason:

A patient upset that his family can only visit during visiting hours. This situation is related to social needs and may not be as immediate a concern as the hostile and angry behaviors described in option C.

A. Increase intake of tea and coffee. B. Exercise daily for at least 20 minutes. C. Sleep until late in the morning. D. Listen to your favorite music. E. Receive a good massage.

Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:

Increasing intake of tea and coffee is incorrect. While some individuals find comfort in warm beverages like tea, excessive intake of caffeinated drinks, such as coffee, can contribute to increased anxiety and disrupted sleep. It's important to moderate caffeine consumption.

Choice B Reason:

Exercising daily for at least 20 minutes is correct. Regular exercise is a well-established stress management technique. Physical activity can help reduce stress hormones and trigger the release of endorphins, promoting a sense of well-being.

Choice C Reason:

Sleeping until late in the morning is incorrect. While adequate sleep is crucial for stress management, sleeping until late in the morning might disrupt a regular sleep schedule. Consistent and quality sleep is essential for overall well-being. Establishing a consistent sleep routine is often recommended.

Choice D Reason:

Listening to your favorite music is correct. Listening to music can have a calming effect and is often used as a relaxation technique. It can help reduce stress and improve mood.

Choice E Reason:

Receiving a good massage is correct. Massage therapy is a known stress-relieving technique. It can help relax tense muscles, reduce anxiety, and promote a sense of relaxation.

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Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

According to Maslow's hierarchy of needs, which situation on an inpatient mental health unit would require priority intervention?

Correct Answer is C

Explanation

Which intervention would the nurse suggest to a patient seeking advice regarding stress management? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

One of the goals of a therapeutic community is for patients to become more autonomous and accept self-responsibility. Which option below best encourages fulfillment of this goal?

The nurse states to the patient "You say that you are sad, but you are smiling..." Which option describes the purpose of this therapeutic communication technique?

A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

The nurse is caring for a patient who consults with family members before making every treatment decision. Based on the nurse's observation. which type of boundary exists within the family structure?

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)

During a group meeting Jack, a patient, shares his fears around his impending discharge. The most appropriate response for the group leader would be?

Which activity would a nurse perform in an inpatient psychiatric unit? Select all that apply. (Select All that Apply.)

Which is a characteristic of therapeutic milieu when caring for a patient in the psychiatric healthcare setting?