A nurse is communicating with a client on an inpatient psychiatric unit. The client moves closer and invades the nurse's personal space, making the nurse uncomfortable. Which is an appropriate nursing intervention?

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Question 1 of 5

A nurse is communicating with a client on an inpatient psychiatric unit. The client moves closer and invades the nurse's personal space, making the nurse uncomfortable. Which is an appropriate nursing intervention?

Correct Answer: B

Rationale: The correct answer is B: The nurse expresses a sense of discomfort and limits behaviors. This is the appropriate intervention because it establishes clear boundaries and communicates the nurse's discomfort while maintaining a therapeutic relationship. By expressing discomfort and setting limits, the nurse asserts their personal space and ensures a safe environment for both parties. Choice A is incorrect because ignoring the behavior doesn't address the issue and may compromise the nurse's well-being. Choice C is incorrect as it passively accepts the invasion of personal space without addressing the discomfort. Choice D is incorrect as it immediately escalates the situation to a confrontational level, which may not be necessary at this stage and could harm the therapeutic relationship.

Question 2 of 5

"QSEN" refers to

Correct Answer: B

Rationale: The correct answer is B: Quality and Safety Education for Nurses (QSEN). This is because QSEN is an initiative that focuses on improving the quality and safety of healthcare by providing education and resources for nurses. It aims to prepare nurses with the knowledge, skills, and attitudes necessary to enhance patient outcomes and reduce medical errors. Choice A is incorrect because it does not accurately represent the purpose of QSEN. Choice C is incorrect as it does not mention the focus on safety and quality in nursing care. Choice D is incorrect as it does not capture the comprehensive nature of the QSEN initiative.

Question 3 of 5

A patient experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's best action.

Correct Answer: C

Rationale: The correct answer is C because it focuses on de-escalation by providing reassurance and support to the patient. By telling the patient to stop running and take a deep breath, the nurse acknowledges the patient's distress and offers assistance. This approach aims to help the patient regain control in a calming manner. Choice A is incorrect because asking for an example may not address the immediate need for de-escalation. Choice B is incorrect as physically restraining the patient could escalate the situation further. Choice D is incorrect as it may provoke feelings of fear or lack of control in the patient by mentioning seclusion.

Question 4 of 5

A psychiatric-mental health nurse working in a Veteran's Administration Medical Center is meeting with a military wife who is an Asian American. The woman is to be joining a support group for wives of veterans who have posttraumatic stress syndrome. When asking her to describe her husband's mental health problems, which response would the nurse most likely expect?

Correct Answer: A

Rationale: The correct answer is A because it highlights a common cultural belief in Asian communities that mental health issues can be attributed to physical causes like vitamin deficiencies. This response indicates the wife's potential perspective and understanding of her husband's mental health problems, which is important for the nurse to consider when providing support. Choice B is incorrect as it perpetuates a negative stereotype about mental health issues being solely caused by war trauma. Choice C is incorrect as it suggests severe symptoms of PTSD without considering the cultural context. Choice D is incorrect as it focuses on the husband's behavior rather than his potential mental health issues and lacks cultural sensitivity.

Question 5 of 5

After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?

Correct Answer: C

Rationale: The correct answer is C: Risk for Suicide. Given the patient's presentation of being tearful, previous suicide attempt, inability to concentrate, sleep disturbances, poor appetite, unkempt appearance, low monotone speech, and lack of eye contact, these are all indicative of suicidal ideation and risk. The nurse should prioritize this nursing diagnosis to ensure the patient's safety. A: Ineffective Role Performance does not address the immediate risk of suicide. B: Risk for Infection is not indicated by the patient's symptoms. D: Risk for Self-Mutilation is not the priority as the patient's immediate risk is suicidal behavior.

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