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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Overidentification is correct. Overidentification refers to a therapist or nurse identifying too closely with the patient, making it difficult to maintain professional boundaries.
Choice B Reason:
Overinvolvement is incorrect. Overinvolvement occurs when a therapist or nurse becomes excessively involved in a patient's life, potentially blurring professional boundaries.
Choice C Reason:
Countertransference is incorrect. Countertransference involves the emotional reactions that the therapist or nurse may have in response to the patient's transference. It reflects the therapist or nurse's unresolved issues and emotional responses triggered by the patient.
Choice D Reason:
Transference is incorrect. Transference occurs when a patient unconsciously projects feelings and attitudes from past relationships onto the nurse or therapist. In this case, the patient is attributing characteristics of being indifferent and cold to the nurse, similar to how they perceive their mother. This phenomenon is a form of unconscious redirection of emotions or attitudes.
Correct Answer is C
Explanation
Choice A Reason:
Countertransference is incorrect. Countertransference involves the therapist's emotional reactions to the client based on the therapist's unresolved issues or feelings. It is not about viewing the client positively.
Choice B Reason:
Genuineness is incorrect. Genuineness, also known as congruence, is the therapist's ability to be authentic and transparent in the therapeutic relationship. While it contributes to a positive therapeutic environment, it is not specifically about viewing the client's worth and strengths.
Choice C Reason:
Positive Regard is correct. Positive regard, as proposed by Carl Rogers in person-centered therapy, refers to the therapist's genuine acceptance and caring for the client. It involves recognizing the client's worth, strengths, and potential for growth. Providing positive regard creates a supportive and nonjudgmental environment that facilitates the client's self-exploration and personal development.
Choice D Reason:
Empathy is incorrect. Empathy involves understanding and sharing the feelings of the client. While it contributes to a positive therapeutic relationship, it does not necessarily focus on viewing the client as having strengths and achievement potential.
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