Difficulty: Medium
Average Score: 84%
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 informing the client that they can only approach the nurse's station once an hour, the nurse is setting a clear boundary and limit on the client's behavior. This helps establish structure and consistency in the therapeutic environment. Setting boundaries is essential in psychiatric care to maintain safety and promote appropriate interactions.
Incorrect Options:
B: Providing reality orientation - This option does not apply in this scenario as the nurse is not providing information to help orient the client to reality.
C: Providing client education in a direct manner - While education may be part of the nursing role, the scenario does not involve direct education.
D: Ensuring physical need fulfillment - The scenario does not address physical needs, but rather the client's behavior at the nurse's station.
Incorrect Options:
B: Providing reality orientation - This option does not apply in this scenario as the nurse is not providing information to help orient the client to reality.
C: Providing client education in a direct manner - While education may be part of the nursing role, the scenario does not involve direct education.
D: Ensuring physical need fulfillment - The scenario does not address physical needs, but rather the client's behavior at the nurse's station.