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The nurse is assessing a newly admitted client with cholecystitis. When performing the admission assessment, which statement by the client is an indicator of optimal mental health?
A. “I don’t need anyone in my life, I manage well on my own.”
B. “I practice yoga regularly since it helps manage any stress I am feeling.”
C. “My family has several people with mental health problems.”
D. “I had a history of alcohol use disorder and have been sober for 2 months.”
B. “I practice yoga regularly since it helps manage any stress I am feeling.”
Individual factors influencing mental health include coping or stress management abilities. Interpersonal factors such as intimacy and a balance of separateness and connectedness are both needed for good mental health, and therefore a healthy person would need others for companionship. A family history of mental illness could relate to the biologic makeup of an individual, which may have a negative impact on an individual’s mental health. A recent history of the use of maladaptive coping mechanisms such as alcohol does not indicate that the client is mentally healthy.
The nurse is using the DSM-5-TR for a newly admitted client diagnosed with bipolar I disorder. Which information will the nurse obtain to assist with the use of this resource?
A. Devise a plan of care for a newly admitted client
B. Predict the client’s prognosis of treatment outcomes
C. Document the appropriate diagnostic code in the client’s medical record
D. Use as a guide for client assessment
D. Use as a guide for client assessment
The DSM-5-TR provides standard nomenclature, presents defining characteristics, and identifies underlying causes of mental disorders. It does not provide care plans or prognostic outcomes of treatment. The DSM-5-TR does not provide coding for record-keeping or billing purposes.
The nurse working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?
A. Temporary detaining orders for clients
B. Decision to practice boarding
C. The revolving door for clients
D. The cost of holding clients in the ED for over 48 hours
Answer: B
Rationale: The practice of boarding is frustrating to health care personnel in EDs since it may interfere with the acute care and emergencies that are required in that setting. Clients become dissatisfied with care, and their families feel as though clients are not receiving the care needed to move through the crisis and some believe an increase in suicide. Provision of an adequate number of psychiatric inpatient beds could better meet the needs of clients and might even decrease homelessness, incarceration, and violence. The revolving door phenomenon is the increase in short-stay admissions repeatedly. Having to obtain a temporary detaining order improves the transition into inpatient care. Cost is not the immediate issue of the nurse.
The nurse is working in an inpatient mental health facility and caring for several clients. Which client is most likely to experience the revolving door phenomenon?
A. A client living with both parents that adheres to prescribed medication regimen
B. A client with a dual diagnosis of heroin use disorder and bipolar I disorder
C. A client that has depression on antidepressants receiving electroconvulsive therapy.
D. A client with an acute situational crisis due to a natural disaster
Answer: B
Rationale: A client with a dual diagnosis including a substance use disorder and a mood disorder is most likely to continue to require inpatient services. Many people have a dual problem of both severe mental illness and a substance use disorder. Use of alcohol and drugs exacerbates symptoms of mental illness, again making rehospitalization more likely. Substance use disorders cannot be dealt within 3 to 5 days typical for admissions in the current managed care environment. A client adhering to a medication regiment and having family support will not likely require readmission frequently. A client with depression and receiving electroconvulsive therapy may receive this on an outpatient basis and not require admission. An acute situational crisis will pass over a period of time with appropriate cognitive behavioral therapy that is used on an outpatient basis.
A client is experiencing a “revolving door effect” due to their mental health disorder. Which is the meaning behind this phenomenon?
A. An overall reduction in incidence of severe mental illness
B. Shorter and more frequent hospital stays for persons with severe and persistent mental illness
C. Flexible treatment settings for the mentally ill
D. Most effective and least expensive treatment settings
Answer: B
Rationale: The revolving door effect refers to shorter, but more frequent, hospital stays. Clients are quickly discharged into the community where services are not adequate; without adequate community services, clients become acutely ill and require rehospitalization. The revolving door effect does not refer to flexible treatment settings for the mentally ill. This phenomenon is known to be costly and inefficient. The revolving door effect does not relate to the incidence of severe mental illness; it is associated with the ongoing treatment of chronic illness.
A client being discharged from a substance use disorder treatment program asks the nurse for a date. The nurse talks to the client about the importance of a therapeutic relationship and its characteristics. Which technique is the nurse using to manage this situation?
A. Defining boundaries
B. Defining therapy
C. Letting the client down gently
D. Reprimanding the client
Answer: A
Rationale: A therapeutic relationship is professional, and there are no mutual social goals; it is focused on meeting the client’s needs and is terminated when the client no longer needs services. It is up to the nurse to maintain professional boundaries. This is a healthy and empathic response, not a reprimand. This is not part of the definition of therapy, though successful therapy includes healthy boundaries
A client diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Which treatment will be most beneficial that the client will receive in this setting?
A. Medical management of symptoms
B. Daily psychotherapy
C. Constant staff supervision
D. Psychological stabilization
Answer: A
Rationale: Community mental health centers focus on rehabilitation, vocational needs, education, and socialization, as well as on management of symptoms and medication. Daily therapies, constant supervision, and stabilization require a more acute care inpatient setting.
A novice nurse accepts a staff position at an inpatient mental health facility. Which basic-level responsibility will the nurse expect to have?
A. Providing clinical supervision
B. Using effective communication skills
C. Adjusting client medications
D. Directing program development
Answer: B
Rationale: Basic-level functions include counseling, milieu therapy, self-care activities, psychobiologic interventions, health teaching, case management, and health promotion and maintenance. Advanced-level functions include psychotherapy, prescriptive authority for drugs, consultation and liaison, evaluation, program development and management, and clinical supervision.
The student nurse is working in a forensic unit of the psychiatric inpatient facility. Which is the nurse’s priority action when a client becomes aggressive?
A. Assist other staff on the unit to take down the client safely
B. Maintain a safe distance from the client and call for assistance
C. Keep the client secluded from others
D. Reinforce boundaries when aggression is seen to maintain a safe environment
Answer: B
Rationale: Maintaining a safe distance in this situation is the priority until the nurse has received assistance from the crisis team. The nurse is not in a position to reinforce boundaries at this time, as the client may perceive the nurse as an outsider and may appear as a threat, thus escalating the situation. Therapeutic settings are for all clients, acceptable behaviors are reinforced, and secluding or isolating the client can foster aggressive behavior.
If a client states, “I carry this lucky rabbit’s foot for luck, my parent did too, and it really works,” which statement by the nurse reflects respect for the client’s belief?
A. “A rabbit’s foot has never brought me luck. I don’t know why people carry them.”
B. “Yes, the rabbit’s foot can bring luck to some.”
C. “I can accept that you feel it is lucky, so let’s get to our activities for the day.”
D. “It is not appropriate to harm small animals for their parts.”
Answer: C
Rationale: At times, a nurse’s values and beliefs will conflict with those of the client or with the client’s behavior. The nurse must learn to accept these differences among people and view each client as a worthwhile person regardless of that client’s opinions and lifestyle. The nurse does not need to share the client’s views and behavior; the nurse merely needs to accept them as different from the nurse’s own and not let them interfere with care.
A client diagnosed with bipolar disorder states to the nurse, “Why did I get this illness? I don’t want to be sick.” Which response will the nurse provide to best respond to the client’s concern?
A. “People who develop mental illnesses often had very traumatic childhood experiences.”
B. “There is some evidence that contracting a virus during childhood can lead to bipolar disorder.”
C. “Sometimes people with mental illness have an overactive immune system.”
D. “The cause is not fully known, but mental illnesses do seem to run in families.”
Answer: D
Rationale: Current theories and studies indicate that several mental disorders may be linked to a specific gene or combination of genes, but that the source is not solely genetic; nongenetic factors also play important roles. A compromised immune system could contribute to the development of a variety of illnesses, particularly in populations already genetically at risk. Maternal exposure to a virus during critical fetal development of the nervous system may contribute to mental illness. Genetic factors are known to be more salient than childhood trauma in the etiology of these disorders.
During a regular home health visit to an older adult client the client states, “I’m old, and my life has no purpose anymore. But promise me you won’t tell anyone.” Which is the best response by the nurse?
A. “Don’t worry, I won’t tell anyone else.”
B. “I’m sorry, but I can’t keep that kind of secret.”
C. “Let’s talk about something to cheer you up.”
D. “What can we do to help you feel better?”
Answer: B
Rationale: Keeping secrets with a client is not permissible, especially when the client’s safety is concerned. The other choices would be inappropriate responses because they do not directly address this important boundary that the client has asked to violate.
A client is prescribed a monoamine oxidase inhibitor (MAOI) for treatment of severe depression. Which statement made by the client indicates that there is understanding of education provided by the nurse related to dietary restrictions?
A. “I am now allergic to foods that are high in the amino acid tyramine.”
B. “Certain foods will cause me to have sexual dysfunction when I take this medication.”
C. “Foods that are high in tyramine will reduce the medication’s effectiveness.”
D. “I will avoid foods that are high in the amino acid tyramine since they can cause severe side effects”
Answer: D
Rationale: Because the enzyme MAOI is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, causing severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness, and cardiac dysrhythmias. Taking an MAOI does not confer allergy to tyramine. Sexual dysfunction is a common side effect of many antidepressants. There is no evidence that foods high in tyramine will increase sexual dysfunction or reduce the medication’s effectiveness.
The nurse is performing a medication reconciliation for a client at a high risk for suicide. Which antidepressant drug identified by the nurse will be best in the treatment of this client and reduces the risk of lethal overdose?
A. Tranylcypromine
B. Sertraline
C. Imipramine
D. Phenelzine
Answer: B
Rationale: SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose, in contrast to the cyclic compounds and the MAOIs. Tranylcypromine and phenelzine are MAOIs. Imipramine is a cyclic compound.
A client prescribed disulfiram experiences facial flushing, a throbbing headache, nausea, and vomiting and states to the nurse that “I only drank one beer.” Which is the best response by the nurse?
A. “This is a mild side effect of the medication, and one beer shouldn’t cause the reaction.”
B. “The reaction that you experienced is an expected response with the ingestion of alcohol.”
C. “This is an idiosyncratic reaction to the medication and is an expected response to treatment.”
D. “You must have a severe allergy to disulfiram that you were not aware of and will need to stop the medication.”
Answer: B
Rationale: Disulfiram is a sensitizing agent that causes an adverse reaction when mixed with alcohol in the body. Five to 10 minutes after a person taking disulfiram ingests alcohol, symptoms begin to appear: facial and body flushing from vasodilation, a throbbing headache, sweating, dry mouth, nausea, vomiting, dizziness, and weakness. These symptoms are not mild side effects because these are very uncomfortable symptoms. These symptoms would not be an idiosyncratic reaction because this is the expected reaction. These symptoms are not indicative of a severe allergy to the medication.
When the client asks the nurse how long it will take before the selective serotonin reuptake inhibitor (SSRI) antidepressant medication will be effective, which reply is most accurate and therapeutic?
A. “This medication will be effective within 20 minutes of the first dose.”
B. “You will have gradual improvement in symptoms over the next 4 to 6 weeks.”
C. “It will probably take months for the medication to work. In the meantime, you should receive psychotherapy.”
D. “It is dependent on how depressed you are. It takes longer the more depressed you are.”
Answer: B
Rationale: SSRIs may be effective in 2 to 3 weeks. Researchers believe that the actions of these drugs are an “initiating event” and that eventual therapeutic effectiveness results when neurons respond more slowly, making serotonin available at the synapses. The medication will not be effective within 20 minutes of the first dose, and it will not likely take months for the medication. Attitude and faith will not improve with the medication’s effectiveness.
A client has a lithium level of 1.2 mEq/L (1.2 mmol/L). Which intervention by the nurse is indicated?
A. Call the health care provider for an increase in dosage
B. Do not give the next dose and call the health care provider
C. Increase fluid intake for the next week
D. No intervention is necessary at this time
Answer: D
Rationale: The lithium level is within the therapeutic range. Serum levels of less than 0.5 mEq/L (0.5 mmol/L) are rarely therapeutic, and a level of more than 1.5 mEq/L (1/5 mmol/L) is usually considered toxic. Consequently, there is no need to liaise with the health care provider or increase fluid intake.
The nurse has developed a therapeutic relationship with a client in the outpatient behavioral health clinic. Which situation is considered a breach of professional boundaries?
A. Client asking a nurse for the nurse’s phone number
B. The nurse refuses a gift from a client.
C. The nurse changes the subject in response to a client’s compliment.
D. The nurse has a lengthy social conversation with a client on the phone.
Answer: D
Rationale: Having a lengthy social conversation with a client would violate professional boundaries. Nurses need to be aware of professional boundaries to avoid exploitation of the client. In a friendship, there is a two-way sharing of personal information and feelings, but in a nurse–client relationship, the focus is on the client’s needs, and the nurse generally does not share personal information or attempt to meet their own needs through the relationship. Indicators that the relationship may be moving outside the professional boundaries are gift giving on either party’s part, spending more time than usual with a particular client, strenuously defending or explaining the client’s behavior in team meetings, the nurse’s feeling that they are the only one who truly understands the client, keeping secrets, or frequently thinking about the client outside of the work situation. Asking the nurse for their phone number would not violate professional boundaries, however, if the nurse responded and gave the client the number, then professional boundaries would be violated.
A client is seen for frequent exacerbation of schizophrenia due to nonadherence to medication regimen. The nurse will assess for which common contributor to nonadherence?
A. The client is symptom-free and therefore does not need to adhere to the medication regimen.
B. The client cannot clearly see the instructions written on the prescription bottle.
C. The client dislikes the weight gain associated with antipsychotic therapy.
D. The client sells the antipsychotics to addicts in the neighborhood.
Answer: C
Rationale: Clients with schizophrenia are less likely to exercise or eat low-fat nutritionally balanced diets; this pattern decreases the likelihood that they can minimize potential weight gain or lose excess weight. Antipsychotics should be taken regularly and not omitted when free of symptoms. Antipsychotics do not adversely affect vision, nor do they have addictive potential.
A nurse is instructing a client on taking lithium for bipolar disorder and the need for blood to be drawn every 2 to 3 days initially. The client states, “I am going to have a hard time getting back every 2 days. Why is this important?” Which is the best response by the nurse?
A. “We want to determine if there is a rebound effect occurring.”
B. “It is important to determine if it is having the maximum therapeutic effect.”
C. “The drug sample will determine the drugs potency and if it is enough for you.”
D. “We want to determine how long the medication stays in your blood stream.”
Answer: B
Rationale: The efficacy of a drug is the maximum therapeutic effect. On clients taking lithium, once this is determined, testing can be done monthly. The potency of a drug refers to the amount of drug needed to achieve efficacy, while the half-life of a drug refers to how long it takes for half of the drug to be removed in the blood stream; neither characteristic is identified by lab testing. The rebound effect is the temporary return of symptoms when medications are discontinued abruptly.
A nurse is recording subjective information from the family of a client with aggressive behaviors brought to the ED via ambulance. Family member states the client does not adhere to the prescribed medication regimen. Which statement by the family determines the family member’s understanding of the client’s illness?
A. “We know the intention was not to take medications, as it was relayed medication was no longer needed.”
B. “Because of mental illness, my sibling cannot think clearly or understand the need for meds.”
C. “This situation occurs because of thoughts that no one cares and to get attention.”
D. “This ‘mental illness’ is used as an excuse to get away with aggressive behavior for years.”
Answer: B
Rationale: Often when clients stop taking their medications or take them improperly, it is a result of faulty reasoning, which is part of the mental illness. There is no indication that the client’s medications have been discontinued, and it is unlikely to be an attention-getting strategy or manipulation ploy. Because mental illness disrupts thinking, flawed thinking is the most likely cause.
The nurse is creating a plan of care for a client experiencing a situational crisis. Which is the mostmeasurable and obtainable goal for the client to achieve?
A. The client will identify possible causes for the crisis.
B. The client will discover a new sense of self-sufficiency in coping.
C. The client will resume the precrisis level of functioning.
D. The client will express anger regarding the crisis event.
Answer: C
Rationale: Crises usually exist for 4 to 6 weeks. At the end of that time, the crisis is resolved in one of three ways. In the first two, the person either returns to their precrisis level of functioning or begins to function at a higher level; both are positive outcomes for the individual. Identification of causes is not a priority outcome of crisis intervention, though it may be relevant in many cases. A new sense of self-sufficiency is beneficial, but this does not necessarily include a resumption of precrisis functioning, which is the priority outcome. Expression of anger at 4 to 6 weeks indicates a less than favorable outcome of crisis intervention.
A client has just been told they have cervical cancer. When asked about how this is impacting them, they state, “It’s just an infection; it will clear up.” Which does this statement by the client indicate to the nurse?
A. There is a need for education on cervical cancer.
B. The client is unable to express their true emotions.
C. The client should be immediately referred to a cancer support group.
D. The client is using denial to protect themself from an emotionally painful thought.
Answer: D
Rationale: Ego defense mechanisms are methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events. Denial is a common strategy for ego defense. Education and referrals are premature at this point and should be reserved for when the client’s failure to accept reality has been addressed.
The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?
A. Facilitate the client's expression of emotions.
B. Establish a therapeutic nurse–client relationship.
C. Teach the client and family necessary self-care skills.
D. Implement interventions designed to address the client's needs.
Answer: B
Rationale: Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when working with clients. It is foundational to each of the other listed nursing actions so it must be established first. Facilitation of the expression of emotions is not a high priority at this time. Implementation and education will be the last goal to achieve.
An adolescent client defies the nurse’s repeated requests to turn off the video game and go to sleep. The client says angrily, “You sound just like my parents!” and continues to play the video game. Which does the nurse identify this statement indicates?
A. The need for stricter discipline at home
B. Early signs of oppositional defiant disorder
C. The presence of transference
D. Expression of developing autonomy
Answer: C
Rationale: Transference occurs when the client displaces onto the therapist various attitudes and feelings that the client originally experienced in other relationships, such as with parents. The occurrence of transference does not indicate ineffective parenting or disciplinary practices, nor is it indicative of a disorder. Autonomy is developed much earlier in the toddler years.
The nurse has established a therapeutic relationship with a client. Which behaviors identified will indicate that the client has entered into the identification phase of the nurse–client relationship?
A. The client is answering questions related to the plan of care.
B. The client is sharing feelings and emotions with the nurse.
C. The client is attending all therapy sessions and utilizing the services provided.
D. The client states that they feel the issues have been resolved and no longer need to come.
Answer: B
Rationale: The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger. The orientation phase is directed by the nurse and involves initially engaging the client in treatment, providing explanations and information, and answering questions. In the exploitation phase, the client makes full use of the services offered. In the resolution phase, the client no longer needs professional services and gives up dependent behavior and the relationship ends.
A nurse is meeting with a crisis support group. Which statement by the nurse will be effective to explain about the crisis experience?
A. “Even happy events can cause a crisis if the stress is overwhelming.”
B. “Only people who have unfortunate life events will experience a crisis.”
C. “A person has no control over how a crisis will affect them.”
D. “People can prevent all crises if they develop good coping skills early.”
Answer: A
Rationale: Not all events that result in crisis are “negative” in nature. Events like marriage, retirement, and childbirth are often desirable for the individual but may still present overwhelming challenges. All individuals can experience a crisis when they confront some life circumstance or stressor that they cannot effectively manage through use of their customary coping skills. Skills for coping with crises can be taught and learned. Even so, it is unrealistic to expect a life that is free of crises, even with well-developed coping skills.
A nursing supervisor reprimands an employee for being chronically late for work. If the employee handles the reprimand using the defense mechanism of displacement, which behavior by the employee will be observed?
A. Arguing with the supervisor that the employee is usually on time
B. Making a special effort to be on time tomorrow
C. Telling fellow employees that the supervisor is picking on the employee
D. Telling the unit housekeeper that the unit housekeeper’s work is sloppy
Answer: D
Rationale: Displacement involves venting feelings toward another, less threatening person. Arguing is denial. Making a special effort is compensation. Telling fellow employees that the supervisor is picking on the employee is projection.
The nurse observes the client experiencing a panic attack in the day room in the behavioral health unit. Which is the priority action by the nurse?
A. Stay with the client and maintain a safe environment.
B. Take the client for a walk around the unit.
C. Redirect the client to an activity or task.
D. Educate the client in ways to prevent a future panic attack.
Answer: A
Rationale: In panic level anxiety, the client may expose themselves to injury and the nurse should stay with the client and ensure that they are safe. The client should not be moved from where they are until they are calm and have their emotions under control. Redirecting the client to an activity or task may be done in moderate anxiety and not in panic anxiety since the client does not experience rational thought at this time. Education is not a priority at this time since the client will not be able to focus.
The nurse observes a client begins to cry after a visitor leaves. Which question is best to ask the client to take the initiative in discussing what is bothering them?
A. “Is there something you would like to talk about?”
B. “What is happening with you?”
C. “I notice that you are crying.”
D. “Would it be alright if I sit here with you?”
Answer: A
Rationale: Broad openings allow the client to take the initiative in introducing the topic such as “Is there something you would like to talk about?” For the client who is hesitant about talking, broad openings may stimulate them to take the initiative. Asking the client “What is happening?” may sound abrupt and demanding. The nurse makes a statement when saying “I notice you are crying.” This will not encourage further expression. Asking the client if it would be alright to sit with them does not elicit more information from the client but does offer self which is therapeutic.
A client who has continuously experienced severe symptoms of schizoaffective disorder for the past 17 years is experiencing an acute psychotic episode. Which level of care is most appropriate for this client at this time?
A. Partial hospitalization
B. Residential treatment
C. Inpatient hospital treatment
D. Clubhouse
Answer: C
Rationale: Long-stay clients in an inpatient setting are people with severe and persistent mental illness who continue to require acute care services despite the current emphasis on decreased hospital stays. This client meets these criteria. Partial hospitalization is designed for patients transitioning to independent living. Residential treatment and the clubhouse model provide supervised independent living, which would be unsafe for a client whose symptoms are severe and persistent.
The nurse is working in the ED and has clients with mental health disorders awaiting admission. Which client is the priority for admission to the inpatient care unit?
A. A client with confusion and disorientation
B. A client with a need for medication changes
C. A client that is at risk for harm to self or others
D. A client experiencing drug or alcohol withdrawal
Answer: C
Rationale: Safety is a priority; the inpatient setting provides safety of the client and/or others. Confusion or disorientation, need for medication changes, and withdrawal from alcohol or other drugs may also require inpatient care, but the priority is safety.
A client has been started on antidepressants. Which interdisciplinary team member is mostresponsible for monitoring effectiveness and side effects of this new medication?
A. Pharmacist
B. Psychiatrist
C. Psychiatric nurse
D. Psychologist
Answer: C
Rationale: The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. The pharmacist has a working knowledge of medications but has limited contact with the patient. The primary function of the psychiatrist is diagnosis of mental disorders and prescription of medical treatments. The clinical psychologist practices therapy.
The client is in the termination phase of the nurse-client relationship after successfully meeting the outcomes of counseling. The client states, “Now that this is over and you won’t be seeing me professionally, let’s go out together.” Which is the best response by the nurse?
A. “I have enjoyed spending time with you professionally but it would be inappropriate for me to see you socially.”
B. “I do not make it a habit to see my clients outside of the professional setting so we won’t be seeing each other again.”
C. “You are welcome to stop by and see me at any time in my office. I would be happy to see you again.”
D. “Now that you are well again, it would be a good idea for you to go out and meet new friends, but I cannot be your friend.”
Answer: A
Rationale: It is appropriate to tell the client that the nurse enjoyed the time spent with the client and will remember them, but it is inappropriate for the nurse to agree to see the client outside the therapeutic relationship. Stating, “I do not make it a habit” is not a professional nor tactful way to set the boundaries for termination. Allowing the client to stop by at their leisure does not effectively terminate the relationship and creates dependency on the nurse. Informing the client that the nurse cannot be their friend may be truthful, but may also leave the client with unresolved feelings of rejection.
A client states, “I am just devastated that my marriage is falling apart.” Which statement made by the nurse best demonstrates an empathetic response?
A. “I feel so bad for what you are going through.”
B. “You feel like your world is falling apart right now.”
C. “I have been divorced, too. I know how hard it is.”
D. “It will get better; let’s talk about it.”
Answer: B
Rationale: Therapeutic communication techniques, such as reflection, restatement, and clarification, help the nurse to send empathetic messages to the client. The nurse’s statement, “You feel like your world is falling apart right now” restates the client’s concern. The nurse must understand the difference between empathy and sympathy (feelings of concern or compassion one shows for another). Sympathy often shifts the emphasis to the nurse’s feelings (“I feel so bad for what you are going through”), hindering the nurse’s ability to view the client’s needs objectively. It is inaccurate and nontherapeutic to state that the nurse has experienced the same feelings as the client. Stating that things will get better provides false reassurance.
The client expresses frustration that the health care provider does not spend enough time with the client when making rounds. The nurse replies, "The providers are very busy. What can I help you with?" Which nontherapeutic technique is the nurse using in response to the client?
A. Belittling
B. Defending
C. Disagreeing
D. Introducing an unrelated topic
Answer: B
Rationale: Defending attempts to protect someone or something from verbal attack. This nurse is defending the doctor's behavior by justifying their lack of interaction with the client. The nurse is not belittling the client's statement, but rather giving a defensive rationale for the client's concern. Disagreeing is opposing the client's ideas, which may cause the client to feel defensive about their point of view or ideas. Introducing an unrelated topic is evidenced when the nurse changes the subject. This takes away the initiative for the client to interact. This nurse is not disagreeing that the doctor is absent and is not introducing another topic to the client.
During a conversation with a client, the client asks the nurse what should be done about the client's "cheating" spouse. The nurse replies, "You should divorce. You deserve better than that." Which nontherapeutic communication technique did the nurse use in the response to the client?
A. Giving information
B. Verbalizing the implied
C. Giving advice
D. Agreeing
Answer: C
Rationale: The nurse should not give advice or tell the client what to do. Advising implies that only the nurse knows what is best for the client. Giving information is therapeutic when the client needs facts, but the nurse's statement is suggesting course of action, not objective information. Verbalizing the implied is a therapeutic communication technique which involves putting clearly into words what the client has suggested, but this client has not suggested divorce. Verbalizing tends to make the discussion less obscure. Agreeing, or giving approval, indicates the client is right or wrong. Nurses should remain neutral when using therapeutic communication skills.
A client states to the nurse, “my parent screamed at me in front of several people in the grocery store when I dropped the eggs.” Which statement will be an empathetic response to this client?
A. "You must have been embarrassed when your parent yelled at you in the grocery store."
B. "You really should find your own housing and get out of the situation with your parent."
C. "Well, it sounds like your parent has difficulty controlling their temper."
D. "Why do you think your parent chose that time and place to yell at you?"
Answer: A
Rationale: This statement empathically conveys the nurse's understanding of the client's feelings. Telling the client to obtain housing is giving advice and the statement about the parent is judgmental; neither statement is therapeutic. Asking the client to speculate about the parent’s behavior does not directly demonstrate that the nurse is empathizing with the client.
The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?
A. Leaning forward with arms on the table sitting directly across from the client
B. Turned slightly to the side of the client with arms folded across the chest
C. Leaning back in the chair next to the client with legs crossed at the knees
D. Sitting upright facing the client with both feet on the floor
Answer: D
Rationale: Closed body positions, such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting. A better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle. Leaning forward toward the client may be perceived as invasive.
The nurse is talking with a client that states, “I am so sad today. It is the anniversary of my parent’s death.” Which response by the nurse may impede the communication process between the nurse and client?
A. “I am sorry you feel sad. Would you like to talk?”
B. “You will feel better tomorrow.”
C. “It’s okay to feel sad about your parents.”
D. “I will sit here with you for a while.”
Answer: B
Rationale: Although the nurse is not intentionally impeding the communication process and intending for the client to feel better, using a statement like “You will feel better tomorrow” is dismissive and nontherapeutic. It does not allow the client to talk about the sadness or feel the nurse is empathetic to the client. Allowing the client to talk about it, giving permission to grieve, or just giving of self are therapeutic responses to the statement.
The nurse is sitting with a client who is crying. After a few minutes, the nurse places one hand on the client's shoulder. Which situation does the nurse use touch with for this client?
A. To express sympathy to the client
B. To assess the client's skin temperature and circulation status
C. To offer comfort and support for the client
D. To extend an offer of friendship to the client
Answer: C
Rationale: Touching a client can be comforting and supportive when it is welcome and permitted. The nurse should not express sympathy to clients, nor should the nurse attempt to be "friends" with clients. This type of touch suggests an interpersonal purpose, not solely physical assessment.
A client remarks, "You know, it's the same thing every time." Which is the most therapeutic response by the nurse?
A. "I understand what you mean."
B. "I'm sure everyone is doing their best."
C. "I'm not sure what you mean. Please explain."
D. "It's the same thing every time?"
Answer: C
Rationale: Sometimes, words, phrases, or slang terms have different meanings and can be easily misunderstood. In this case, it is important for the nurse to clarify the meaning in order to avoid making assumptions. Stating that everyone is doing their best is a response that is based on an assumed meaning. Restating the client's statement will not necessarily provide clarification. Stating, "I understand" is simplistic and inaccurate because the nurse cannot claim to fully understand the client's situation.