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 ["B","C","D","E"]

Explanation

Choice A Reason:

The coping skills (Choice A) may be observed and assessed as part of the broader clinical picture, but they are not typically specific components of a formal Mental Status Examination.

Choice B Reason:

Ability to perform calculations. This assesses the client's cognitive abilities, specifically related to mathematical reasoning and problem-solving.

Choice C Reason:

Recall ability. Assessing recall ability helps evaluate the client's short-term memory, which can be impaired in individuals with dementia.

Choice D Reason:

Long-term memory. Evaluating long-term memory provides insights into the client's ability to recall information from the distant past, which is another aspect of cognitive function.

Choice E Reason:

Level of orientation. Assessing orientation to time, place, and person is crucial in understanding the client's awareness of their surroundings and current circumstances, which can be affected in dementia.

A. "Now that we've discussed your reasons for being here and how often we will meet. I'd like to talk about what we will do at the time of your discharge." B. "You are being discharged today, so I’d like to bring up the subject of termination which includes discussing your time here and summarizing what coping skills you have attained. C. "Now that we are working on your problem-solving skills and the behaviors you'd like to change like to bring up the issue of termination D. Haven’t met my new patient yes, but am working through my findings of anxiety in dealing with patient who wanted to kill herself

Correct Answer is C

Explanation

Choice A Reason:

"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." This option seems to introduce the topic of termination prematurely, especially if the client's issues and goals haven't been adequately addressed yet.

Choice B Reason:

"You are being discharged today, so I'd like to bring up the subject of termination, which includes discussing your time here and summarizing what coping skills you have attained."This option presents termination at the time of discharge without prior discussion or collaboration with the client.

Choice C Reason:

"Now that we are working on your problem-solving skills and the behaviors you'd like to change, I'd like to bring up the issue of termination." In therapeutic relationships, termination is an essential phase that involves discussing the ending of the relationship and summarizing the progress made. Bringing up the topic of termination when actively working on the client's goals and issues is appropriate. It allows for a collaborative discussion about the achievements, future plans, and coping strategies that the client has developed during the therapeutic process.

Choice D Reason:

"I haven't met my new patient yet, but am working through my feelings of anxiety in dealing with a parent who wanted to kill herself." This statement is not related to the discussion of termination in the ongoing nurse-patient relationship.

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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

A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply)

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

Explanation

Which statement reflects an accurate understanding of when termination would first be discussed as part of the nurse-patient relationship?

Correct Answer is C

Explanation

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

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