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Zorluk: OrtaMental Health Concepts

A nurse is co-facilitating a group therapy session on an inpatient psychiatric unit. A client diagnosed with major depressive disorder suddenly stands up, states, "There is no point in me being here. I am just a burden to everyone," and walks toward the door. Which action by the nurse is the most appropriate?

  1. Follow the client into the hallway and state, 'It sounds like you are feeling overwhelmed. I am going to stay with you.'Cevap
  2. B
    Ask the client, 'Why do you believe that your presence is a burden to the rest of the group?'
  3. C
    Encourage the client to sit back down by stating, 'You are not a burden, and we all want you to get better.'
  4. D
    Instruct the unlicensed assistive personnel (UAP) to follow the client and monitor them for any self-harming behaviors.

Cevap

The most appropriate action is to follow the client into the hallway, acknowledge their feelings of being overwhelmed, and offer self by staying with them.
The correct response prioritizes both client safety and therapeutic communication. By following the client into the hallway, the nurse ensures continuous monitoring of a potentially unstable individual. Stating an observation about their feelings ('feeling overwhelmed') validates the client's distress without judgment. 'Offering self' ('I am going to stay with you') demonstrates unconditional positive regard, provides a sense of security, and opens the door for further therapeutic dialogue.

Adım Adım Çözüm

1
Analyze the client's statement and physical behavior.
The client is expressing deep feelings of worthlessness and hopelessness ('I am just a burden') and is abruptly leaving a therapeutic environment.
Recognizing signs of acute emotional distress and potential risk for self-harm is the initial priority in psychiatric nursing.
2
Determine the priority nursing intervention based on safety and scope of practice.
The registered nurse must personally assess and ensure the safety of this unstable client rather than delegating the task.
A client in acute distress requires clinical judgment and assessment, which is outside the scope of practice for unlicensed assistive personnel.
3
Select the most therapeutic communication technique to use upon approaching the client.
The nurse should acknowledge the client's distress and 'offer self' by remaining present.
This approach builds trust, validates the client's emotional experience, and provides immediate safety monitoring without putting the client on the defensive.

Anahtar Kavram

Therapeutic Communication and Safe Delegation in Psychiatric Emergencies
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Konular

Mental Health Concepts

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