Nokea
A client has been making sexual comments when communicating with the nurse. The nurse wants to spend some time talking to the patient while respecting the patient's right to privacy. Which setting would be the most appropriate setting for the nurse to talk with the client?
- A. In the patient's room when the patient's roommate is present and 3 feet away
- B. At the nurse's station when other clients and visitors are less than 4 feet away
- C. In an interview room in a remote section of the unit with the nurse 1 foot away from the patient
- D. In a quiet corner of the dayroom at least 4 feet away from others
Correct Answer: D
Rationale: A quiet corner of the dayroom, at least 4 feet from others, balances privacy with safety, avoiding isolated settings or crowded areas that compromise confidentiality.
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Which of the following distance zones is acceptable for people who mutually desire personal contact?
- A. Social
- B. Intimate
- C. Personal
- D. Public
Correct Answer: B
Rationale: The intimate zone (0-18 inches) is suitable for those desiring personal contact, like close family, unlike social, personal, or public zones meant for other interactions.
Which of the following statements would be an empathetic response in a client interaction?
- A. You must have been embarrassed when your father yelled at you in the grocery store.
- B. You really should find your own housing and get out of the situation with your father.
- C. Well, it sounds like your father has difficulty controlling his temper.
- D. Why do you think your father chose that time and place to yell at you?
Correct Answer: A
Rationale: An empathetic response conveys understanding of the client's feelings, like embarrassment, without judgment or advice, as seen in the first option.
A client is fearful and reluctant to talk. Which of the following techniques is most effective when trying to engage the client in interaction?
- A. Broad opening
- B. Focusing
- C. Giving information
- D. Silence
Correct Answer: A
Rationale: Broad openings allow a fearful client to choose what to discuss, reducing pressure and encouraging interaction, unlike focusing or silence which may intimidate.
The nurse must be alert to the nonverbal expressions of the client. Because the meaning attached to nonverbal behavior is subjective, it is important for the nurse to
- A. Increase the client's awareness of nonverbal behavior.
- B. Investigate the source of nonverbal behavior.
- C. Validate the client's feelings.
- D. Validate the meaning of the nonverbal behavior.
Correct Answer: D
Rationale: Validating the meaning of nonverbal behavior ensures the nurse accurately interprets the client's cues, avoiding assumptions before exploring sources or feelings.
A patient yells, 'All the nurses here are so mean. None of you really care about us!' The most therapeutic response would be,
- A. I cannot allow you to yell like that.
- B. We care about you.
- C. Oh, really?
- D. You seem very irritated.
Correct Answer: D
Rationale: Reflecting the client's feelings, like irritation, acknowledges their emotions and encourages further expression, fostering a therapeutic dialogue.