Difficulty: Medium
Average Score: 77%
Simulated
A client on an acute psychiatric inpatient unit approaches the nurse's station every 10-15 minutes with various requests. The nurse intervenes by stating,You may approach the nurse's station only once an hour. Which nursing intervention has been employed?
Correct answer
A
Rationale
The correct answer is A: Confirming boundaries by setting limits on behavior. By instructing the client to approach the nurse's station only once an hour, the nurse is establishing clear boundaries and limits on the client's behavior. This intervention helps maintain structure and consistency within the unit, promotes appropriate interaction patterns, and prevents the client from becoming overly dependent on constant attention.
Other choices are incorrect because:
B: Providing reality orientation is not the correct response in this situation as the client's behavior is not related to confusion or disorientation.
C: Providing client education in a direct manner is not relevant to the scenario where the issue is about setting boundaries for behavior.
D: Ensuring physical need fulfillment is not the appropriate intervention in this case as the client's requests are not related to physical needs.
Other choices are incorrect because:
B: Providing reality orientation is not the correct response in this situation as the client's behavior is not related to confusion or disorientation.
C: Providing client education in a direct manner is not relevant to the scenario where the issue is about setting boundaries for behavior.
D: Ensuring physical need fulfillment is not the appropriate intervention in this case as the client's requests are not related to physical needs.