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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
The comment "I haven't gotten my period yet, and all my friends have theirs" reflects a common concern among adolescents regarding physical development and peer comparison. While this can cause anxiety, it is generally a normal part of adolescent development. The nurse can reassure the adolescent that the timing of puberty varies widely and that it is normal to develop at a different pace than peers.
Choice B Reason:
The concern about a pimple on the face, "There's a big pimple on my face, and I worry that everyone will notice it," is typical of adolescent worries about appearance and self-esteem. While it is important to address these concerns and provide support, it is not as urgent as addressing potential social isolation or mental health issues.
Choice C Reason:
The statement "My parents treat me like a baby sometimes" indicates a common struggle for independence among adolescents. This issue can be addressed through family counseling and communication strategies to help the adolescent and parents navigate this developmental stage. However, it does not indicate an immediate risk to the adolescent's well-being.
Choice D Reason:
The comment "None of the kids at this school like me, and I don't like them either" is the most concerning and should be the nurse's priority. This statement suggests social isolation and potential feelings of depression or low self-esteem. Social isolation can have significant negative impacts on an adolescent's mental health and development. It is crucial for the nurse to explore this further, provide support, and possibly refer the adolescent to a mental health professional.
Correct Answer is A
Explanation
Choice A Reason:
Increased impulsive behaviors can be a sign of heightened risk for suicide, especially in clients with bipolar disorder. Impulsivity may lead to acting on suicidal thoughts without considering the consequences. It's important for the nurse to monitor such changes closely and take appropriate safety measures.
Choice B Reason:
Expressing a desire to go home to be with family does not typically indicate a risk for suicide. It may reflect a client's natural longing for familiar surroundings and support systems, which can be part of a healthy desire for integration back into their community.
Choice C Reason:
Identifying with the problems of other clients often indicates a level of empathy and understanding, which can be beneficial in group therapy settings. It does not inherently suggest a risk for suicide.
Choice D Reason:
Participation in activities, such as playing basketball, is generally a positive sign indicating engagement and social interaction. It can be a part of the client's recovery process and does not suggest an increased risk for suicide.
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