A client in the psychiatric unit begins to laugh and appears to be talking with someone, though the nurse sees no one else in the room. What should the nurse do first?
A) Open the door to the quiet room so the client can use it.
B) Go into the room and sit down beside the client.
C) Walk quietly by and do not disturb the client.
D) Stand at the door and ask if the client is talking to him/herself.
Question 2
The nurse notices burn marks on a client's arms that were not noted in the medical record. When questioned about the marks the client responds with, Oh, sometimes I accidentally burn myself with my cigarette..
The nurse asks, How does that happen? The client smiles and says, Well, maybe it really isn't an accident.. What is the relationship between the behavior and the client's feelings? A) The client wants the nurse to know that the burns are no big deal..
B) The client is describing a lack of control over the impulses to self-injure.
C) The client is telling the nurse that these are intentional acts used to cope.
D) The client is expressing suicidal intentions.
A nurse adjusts the rate of a client’s IV.
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