Which strategies would be helpful for the nurse to use when ...

[NguyenJ]

Which strategies would be helpful for the nurse to use when gathering assessment data about a client
 
  whose family has indicated that he is very suspicious and believes the FBI has him under
  surveillance? (More than one answer may be correct.)
  A. Ask the client to identify the problem as he sees it.
  B. Seek information about when the problem began.
  C. Listen to the client's theory about the cause of the problem.
  D. Tell the client his ideas are not realistic.
  E. Reassure the client of his safety.
  F. Tell the client that staff will control his behavior

Question 2

The nurse planning care for a client should strive to select valid nursing interventions. The best way
  of achieving this outcome is to select relevant interventions
 
  a. suggested by experienced unit nurses.
  b. clients have reported to be helpful.
  c. that are research derived.
  d. that seem logical.

[prumorgan]

Answer to Question 1

ANS:
A, B, C, E
Rationale: During the assessment interview the nurse should listen attentively and accept the client's
statements in a nonjudgmental way. Because the client is suspicious and fearful, reassuring him of
his safety may be helpful, although he is unlikely to trust the nurse so early in the relationship.
Option D suggests to the client that the nurse is not willing to try to understand his views. Option F
may be perceived as a threat.

Answer to Question 2

ANS: C
Research-derived interventions are evidence-based interventions. The nurse can rely on their proven
effectiveness. Option A: Interventions suggested by unit nurses may be largely unproven and
subjectively derived. Option B: Client-reported preferences can be skewed. Option D: This criteria is
quite subjective because what one nurse sees as logical might be perceived differently by another.

[NguyenJ]

TYSM

[cdmart10]

Excellent