The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation?

I'm sorry you are sad. Is there anything I can do to help you feel better?"

"Pipe don't cry. It will get better."

"You look very sad. What is happening?"

"know you are upset but things will look better tomorrow

Answer and Explanation

The Correct Answer is C

Option C demonstrates empathy and active listening. By acknowledging the client's emotions and expressing concern, the nurse creates a safe and supportive environment for the client to share their feelings. This response encourages the client to open up and express what they are going through, allowing the nurse to better understand the situation and provide appropriate care and support.

Options A and D are also empathetic but may not prompt the client to share their feelings or concerns as effectively as Option C.

Option B is not appropriate as it minimizes the client's emotions and may discourage them from expressing their feelings further.

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Correct Answer is A

Explanation

When a nurse observes another nurse acting flirtatiously and bringing small gifts to a client in the behavioral health unit, it raises concerns about professional boundaries and the potential for unethical behavior. The priority action for the observing nurse is to protect the rights and well-being of the client.

Option A, reporting the behavior to the supervisor, is the appropriate course of action. Reporting the observed behavior to the supervisor ensures that the situation is investigated and addressed by the appropriate authorities within the healthcare facility. This action helps maintain the integrity of the therapeutic relationship between the client and healthcare team and protects the client from any potential exploitation or manipulation.

Options B, C and D are not appropriate actions:

B. Ignoring the behavior is not appropriate as it does not address the concerns about professional boundaries and the potential for unethical behavior. Ignoring such behavior may allow it to continue, potentially putting the client at risk.

C. Confronting the nurse directly without first reporting the behavior to the supervisor may not be the most appropriate course of action. It is essential to involve the appropriate authorities within the healthcare facility to conduct a proper investigation and address the situation professionally.

D. Discussing the situation with the client and making assumptions about emotional manipulation may not be appropriate or accurate. It is not the observing nurse's role to discuss such matters with the client. Instead, the appropriate course of action is to report the observed behavior to the supervisor or appropriate authority within the healthcare facility.

A. Call security and ask them to detain the client from leaving. B. Contact the client's family to request they convince the client to stay. C. Allow the client to leave, with a referral to community resources for follow-up care. D. Contact the psychiatrist for initiation of commitment proceedings.

Correct Answer is D

Explanation

In this situation, the client's safety is of utmost importance. Expressing a desire to leave the facility and harm oneself with a gun raises serious concerns about the client's safety and the risk of harm to themselves. Initiating commitment proceedings, also known as involuntary hospitalization or psychiatric hold, allows the facility to legally detain the client temporarily for their protection and evaluation by mental health professionals. This allows for a thorough assessment of the client's mental health status and the formulation of a comprehensive treatment plan to ensure their safety.

Options A, B, and C are not appropriate in this situation:

A. Calling security to detain the client may escalate the situation and could potentially lead to increased risk of harm.

B. Contacting the client's family may not be enough to ensure the client's safety, and it is essential to involve mental health professionals in evaluating the client's risk.

C. Allowing the client to leave without addressing their expressed suicidal ideation is not safe, as the client may be at high risk for self-harm or suicide. Simply referring them to community resources without further evaluation and intervention is not sufficient to address the immediate safety concern.

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The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

Correct Answer is A

Explanation

A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

Correct Answer is D

Explanation

A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior?

The nurse is meeting with a client who is experiencing complicated grieving from the death of their child to suicide. In order to establish a therapeutic nurse-client relationship, what will the nurse do prior to the meeting?

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse. "What do you think about that?" Which is the best response by the nurse?

An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

A nurse is working with a client who has frequent angry outbursts which is disrupting life at home. Which statement by the nurse is most helpful when working with this client?