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 A
Explanation
Choice A Reason:
Safety needs is correct. In this scenario, the individual's safety is compromised both at work (due to the potential layoff) and at home (due to intimate partner violence). Safety needs, which include physical and emotional security, are fundamental in Maslow's hierarchy and take precedence over other needs in this situation.
Choice B Reason:
Physiological needs is incorrect. While a possible layoff can impact financial stability, it may not directly threaten immediate access to basic physiological needs like food, water, and shelter. The immediate safety concern takes precedence.
Choice C Reason:
Love and belonging needs is incorrect. Although witnessing intimate partner violence can strain relationships and affect the sense of belonging, the primary concern in this scenario is the immediate threat to safety.
Choice D Reason:
Esteem needs is incorrect. The threat of a layoff and exposure to domestic violence can impact self-esteem, but the more critical issue at the moment is ensuring physical safety.
Correct Answer is C
Explanation
Choice A Reason:
"Your husband is making really good progress" This statement assumes a positive or negative judgment about the husband's progress without first understanding the spouse's concerns. It may not address the spouse's immediate emotional needs or allow them to express their feelings.
Choice B Reason:
"Crying helps us let things out and we feel better". While this statement acknowledges the act of crying as a way to express emotions, it doesn't directly address the specific concerns of the spouse or invite further communication about the issues causing distress.
Choice C Reason:
"Tell me what is concerning you. “This is a therapeutic nursing response because it encourages the spouse to express their concerns and share their feelings. It opens up communication and allows the nurse to better understand the specific issues or worries that the spouse is experiencing. This response demonstrates active listening and a genuine interest in the spouse's perspective, fostering a supportive and empathetic therapeutic relationship.
Choice D Reason:
"Did your husband say something to upset you?" This question assumes that the spouse's distress is solely related to something the husband said. It may not be the most open-ended or empathetic way to encourage the spouse to share their concerns and might direct the focus too narrowly.
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