The nurse is caring for a client who expresses concerns about sexual orientation. When using the PLISSIT model, which step will the nurse take first?

Provide information about sexual orientation and comment on alternatives.

Communicate an open, accepting attitude.

Provide a referral for the client to see a sex therapist.

Teach the client about normal sexual health.

Answer and Explanation

The Correct Answer is B

A. Provide information about sexual orientation and comment on alternatives: This step involves providing information about sexual orientation and discussing alternatives. However, it may not be the first step in the PLISSIT model. First, the nurse should establish a supportive and nonjudgmental environment, which is addressed in option B.

B. Communicate an open, accepting attitude: This is the correct response. In the PLISSIT model, the first step is to establish an open, accepting attitude. This involves creating a safe space for the client to express their concerns without fear of judgment or discrimination. By demonstrating acceptance and empathy, the nurse encourages the client to feel comfortable discussing sensitive topics related to sexual orientation.

C. Provide a referral for the client to see a sex therapist: Referral to a sex therapist may be appropriate for clients who require specialized intervention beyond the nurse's scope of practice. However, in the PLISSIT model, referral to a specialist typically occurs after the initial steps of establishing rapport and assessing the client's needs.

D. Teach the client about normal sexual health: While education about normal sexual health is an important aspect of sexual health nursing, it may not be the first step in the PLISSIT model. Initially, the focus is on creating a supportive environment and building trust with the client.

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Correct Answer is A

Explanation

This statement raises concern because it suggests that the client is experiencing thoughts of hopelessness and suicidal ideation. Expressions of feeling overwhelmed by pain to the extent of questioning the desire to continue living indicate a need for immediate attention and intervention to address the client's emotional distress and ensure their safety.

B. This statement indicates the client's proactive approach to pain management by taking medication preemptively before pain becomes severe. It reflects an understanding of pain management strategies and a willingness to address pain effectively.

C. Although this statement acknowledges the challenge of coping with pain, it also suggests the client's attempts to cope by mentally dissociating from the pain. While coping mechanisms vary among individuals, this response does not raise immediate concern unless accompanied by more severe signs of distress.

D. This statement acknowledges the chronic nature of the client's pain and its impact on daily activities but does not indicate thoughts of self-harm or severe emotional distress. It reflects the client's adaptation to living with pain and a willingness to engage in activities despite its presence.

A. Trash can accidentally left in path to bathroom B. States, "I think I only bruised my left knee." C. Noncompliant with use of call bell D. Seems angry and upset

Correct Answer is A

Explanation

A. Trash can accidentally left in path to bathroom: This option accurately documents the environmental factor that contributed to the client's fall. It provides relevant information about the incident, highlighting the presence of a hazard (the trash can) in the path to the bathroom, which led to the fall. Documenting such environmental factors is essential for identifying safety issues and implementing preventive measures.

B. States, "I think I only bruised my left knee": While documenting the client's statement about the extent of their injury is important for assessing and addressing their physical condition, it does not directly address the environmental factor that contributed to the fall. This information may be included in the assessment section of the chart but may not fully capture the circumstances surrounding the fall.

C. Noncompliant with use of call bell: This statement implies a judgment about the client's behavior rather than documenting the circumstances of the fall. While noncompliance with safety measures such as using the call bell may contribute to falls, it is important to focus on objective observations and environmental factors that directly contributed to the incident.

D. Seems angry and upset: Documenting the client's emotional state is relevant for understanding their response to the fall and providing appropriate psychosocial support. However, it does not directly address the cause of the fall or provide information about the environmental factor (the trash can) that contributed to the incident.

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The nurse is caring for a client who expresses concerns about sexual orientation. When using the PLISSIT model, which step will the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?

Correct Answer is A

Explanation

The nurse is caring for a client who trips and falls over a trash can left in the path to the bathroom. Which is part of an appropriate charting entry?

Correct Answer is A

Explanation

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