Nokea
A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears?
- A. Open-ended questions and silence
- B. Offering personal opinions about the need to eat
- C. Verbalizing reasons why the client may choose not to eat
- D. Focusing on self-disclosure of the nurse's own food preferences
Correct Answer: A
Rationale: Open-ended questions and silence are strategies that are used to encourage clients to discuss their feelings in a descriptive manner. Options 2 and 3 are not helpful to the client because they do not encourage the expression of personal feelings. Option 4 is not a client-centered intervention.
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While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit the most useful response for determining the client's degree of adjustment to the new diagnosis?
- A. Is there anyone to help with housework and shopping?'
- B. How do you feel about making changes to your lifestyle?'
- C. Do you understand the schedule for your new medications?'
- D. Did you make a follow-up appointment with your provider?'
Correct Answer: B
Rationale: Exploring feelings assists the nurse with determining the individualized plan of care for the client who is adjusting to a new diagnosis. The correct option is the best question to ask the client because it is likely to elicit the most revealing information about the client's feelings about CAD and the requisite lifestyle changes that can help maintain health and wellness. The remaining choices are aspects of post-hospital care, but they are unlikely to uncover as much information about the client's adjustment to CAD because they are closed-ended questions.
A client diagnosed with delirium anxiously states, 'Look at the spiders on the wall.' Which response by the nurse addresses the client's concerns therapeutically?
- A. Would you like me to kill the spiders for you?'
- B. While there may be spiders on the wall, they are not going to hurt you.'
- C. I know that you are frightened, but I do not see any spiders on the wall.'
- D. You are having a hallucination; I'm sure there are no spiders in this room.'
Correct Answer: C
Rationale: When hallucinations are present, the nurse should reinforce reality with the client while acknowledging the client's feelings as the correct option does. Eliminate options 1, 2, and 4 because they do not reinforce reality but rather support the legitimacy of the hallucination or that reinforces reality but does not address the client's feelings.
The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?
- A. Elevating the affected leg is indicated.'
- B. Keeping the affected leg flat encourages healing.'
- C. Engaging in activity as tolerated should be encouraged.'
- D. Maintaining bathroom privileges is the most important action.'
Correct Answer: A
Rationale: The nurse plans to elevate the affected extremity because this facilitates venous return by using gravity to improve blood return to the heart, decreases venous pressure, and helps relieve edema and pain. Option 2 does not facilitate venous return and thus is not indicated for a client with thrombophlebitis. Options 3 and 4 are unsuitable activities for a client on bed rest.
The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority?
- A. Directing the discussions so that teaching needs are met
- B. Focusing directly on the client's message regarding needs
- C. Reflecting only facts related to the client's expressed concerns
- D. Reacting to the client's responses in a matter-of-fact, professional manner
Correct Answer: B
Rationale: For effective communication, the nurse uses active listening and assesses for verbal and nonverbal communication to receive the client's intended message, thus creating an environment in which the client feels comfortable expressing feelings. An authoritarian approach is directive and not permissive, and it is unlikely to create an environment for the free exchange of thoughts and ideas. Reflecting facts only is a barrier to effective communication because subjective information can also provide a stimulus for effective communication. Reacting in a matter-of-fact manner can be an ineffective strategy for facilitating communication.
A client has been using crutches to ambulate for 1 week and now reports pain, fatigue, and frustration with crutch walking. How should the nurse respond when the client states, 'I feel like I will always be crippled'?
- A. Tell me what makes this so bothersome for you.'
- B. I know how you feel. I had to use crutches before too.'
- C. Why don't you take a couple of days off of work and rest?'
- D. Just remember, you'll be done with the crutches in another month.'
Correct Answer: A
Rationale: The correct option demonstrates the therapeutic communication technique of clarification and validation and indicates that the nurse is dealing with the client's problem from the client's perspective. Option 2 devalues the client's feelings and thus blocks communication. Option 3 gives advice and is a communication block. Option 4 provides false reassurances because the client may not be done with the crutches in another month. Additionally, it does not focus on the present problem.