You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the floor.
What is your first step in the nursing process in this situation?
Leave the patient to get help.
Call the patient’s health-care provider from your cell phone.
Help the patient get up and then document your findings in the chart.
Gather more information by making observations about the patient.
The Correct Answer is D
The first step in the nursing process is assessment, which involves gathering information about the patient’s condition. In this situation, the nurse should make observations about the patient’s physical and mental status, including any signs of injury or distress. This information can then be used to determine the appropriate course of action and provide appropriate care. The other
The other options do not represent the first step in the nursing process and may not be appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Why did you do that? - This question can come across as judgmental and accusatory, and may cause the client to become defensive or feel criticized.
Tell me more about your relationship with your daughter? - This question encourages the client to open up and share more about themselves, which can promote effective communication.
This is what I think you should say. - This response takes away the client's autonomy and can make them feel like their feelings and opinions are not important.
Don’t stress over it, everything will turn out fine. - This response minimizes the client's concerns and can make them feel like their feelings are not valid or important. It can also come across as dismissive and unempathetic.
Correct Answer is C
Explanation
The nurse’s ability to listen and observe the client’s verbal and non-verbal messages. Effective communication in the mental health setting requires the nurse to actively listen to the client and to pay close attention to their verbal and non-verbal cues. By doing so, the nurse can better understand the client’s needs and concerns and can provide appropriate support and guidance.
While the nurse’s understanding of mental health disorders (b) and their relationship with the client (d) can also play a role in effective communication, the ability to listen and observe is a fundamental skill that is essential for effective therapeutic communication. The client’s ability to communicate (a) is also important, but it is ultimately the nurse’s responsibility to use effective communication techniques to facilitate the therapeutic process.
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