Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

"You should try to see your partner's point of view before your own."

"Tell me more about the concerns that you have regarding your marriage."

"We could develop a plan for how to talk about this with your partner."

"Relationship difficulties are stressful and require effort to resolve."

Answer and Explanation

The Correct Answer is A

Choice A reason:

This statement may require intervention by the charge nurse because it suggests the nurse is taking a directive approach, potentially overstepping professional boundaries. It implies that the client's perspective is less important than their partner's, which could undermine the therapeutic relationship and the client's sense of autonomy.

Choice B reason:

Asking the client to elaborate on their concerns is a therapeutic communication technique that encourages expression and exploration of feelings. It does not require intervention as it is supportive and facilitates the nurse-client relationship.

Choice C reason:

Offering to help the client develop a plan to discuss their concerns with their partner is a constructive approach that empowers the client. It promotes problem-solving and does not necessitate intervention by the charge nurse.

Choice D reason:

Acknowledging that relationship difficulties are stressful and require effort to resolve is an empathetic statement that validates the client's experience. It is supportive and does not require intervention.

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Correct Answer is A

Explanation

Choice A Reason:

Attempting to climb out of bed and expressing an urgent need to get home can be indicative of delirium, especially in older adults. Delirium is characterized by an acute change in mental status, which includes confusion, disorientation, and a lack of awareness of one's surroundings¹². This behavior reflects the client's impaired perception of reality and potential disorientation to time and place, which are common in delirium.

Choice B Reason:

Refusal to get out of bed and a lack of motivation for personal hygiene could suggest depression or a physical ailment rather than delirium. While hypoactive delirium can present with decreased activity and apathy, it is also accompanied by other cognitive impairments, which are not mentioned in this choice.

Choice C Reason:

Wanting to know the current time despite the presence of a clock may indicate cognitive impairment, but it is not a definitive sign of delirium. It could be related to vision problems, lack of attention, or other cognitive issues not necessarily associated with delirium.

Choice D Reason:

Requesting extra blankets when the room is adequately warm might suggest discomfort or a subjective feeling of cold, which can be seen in various conditions, including infections or metabolic imbalances, but it is not specific to delirium.

A. Speak to the patient using an authoritative voice and ask them, "Why are you acting this way?" B. Use clarification to determine what the patient is feeling. C. Move the patient to a private area so the conversation will not be disturbed and cannot be seen. D. Never break constant eye contact with the patient.

Correct Answer is B

Explanation

Choice A reason:

Speaking to a patient using an authoritative voice can often escalate the situation, especially when the patient is already angry and aggressive. It may be perceived as confrontational or patronizing, which can further provoke the patient's anger.

Choice B reason:

Clarification is a therapeutic communication technique that helps in understanding the patient's feelings and the reasons behind their behavior without making assumptions. It allows the nurse to express concern and willingness to listen, which can help de-escalate the situation.

Choice C reason:

While moving a patient to a private area can be beneficial in some cases, it should be done with caution. The priority is to ensure safety for both the patient and staff. If moving the patient could potentially escalate their aggression or if they perceive it as isolation, it might not be the best immediate action.

Choice D reason:

Maintaining eye contact is generally considered good practice in communication as it shows attentiveness. However, in situations where a patient is aggressive, constant eye contact could be interpreted as a challenge or threat, potentially escalating aggression.

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Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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