Nokea
A client with a new diagnosis of type 1 diabetes mellitus has been seen for 3 consecutive days in the emergency department with hyperglycemia. During the assessment, the client states to the nurse, 'I'm sorry to keep bothering you every day, but I just can't give myself those awful shots.' Which therapeutic comment is most appropriate for the nurse to respond?
- A. I couldn't give myself a shot either.
- B. You must learn to give yourself the shots.
- C. Let me see if we can change your medication.
- D. Have you had instructions on injecting yourself?
Correct Answer: D
Rationale: It is important to determine and deal with a client's underlying fear of self-injection. The nurse should determine whether a knowledge deficit exists. Positive reinforcement should occur rather than focusing on negative behaviors. Demanding that the client perform a behavior or skill is inappropriate. The nurse should not offer a change in regimen that cannot be accomplished.
You may also like to solve these questions
A client is suspected of having posttraumatic stress disorder. Which problem is the most important for the nurse to assess?
- A. panic attacks
- B. anorexia
- C. suicide
- D. short-term memory loss
Correct Answer: C
Rationale: Suicide risk is the most critical to assess in PTSD due to high rates of suicidal ideation and attempts.
The nurse is caring for a client who is having surgery the next morning. The client says, 'I'm really scared about surgery. I've never been put to sleep before and I'm afraid I might not wake up.' Which response by the nurse is the most therapeutic?
- A. Why are you worried about such a minor procedure?
- B. We can call the doctor and cancel the surgery if you would prefer.
- C. It's normal to be afraid of something new like surgery. Tell me how you feel.
- D. Don't worry, you have a really good doctor and he will see to it that nothing goes wrong.
Correct Answer: C
Rationale: Acknowledging fear as normal and encouraging the client to express feelings (C) is therapeutic, promoting open communication. Minimizing concerns (A), suggesting cancellation (B), or offering false reassurance (D) dismisses the client's emotions.
A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, 'I am so afraid my baby is going to die.' Which response by the nurse to the client is best?
- A. Finding out your baby has a serious health problem must be painful.
- B. How does your husband feel about this problem?
- C. How is your baby doing now?
- D. What you need to do is to focus on the present.
Correct Answer: A
Rationale: Acknowledging the client’s pain validates their fear and opens therapeutic communication, supporting emotional processing. Asking about others, focusing on the fetus’s status, or directing focus to the present dismisses the client’s expressed fear.
The nurse was assigned to the mental health care area from another area in the facility. A client accuses the nurse of being a terrorist with poisonous pills when the nurse is preparing medications. Which response by the nurse is best?
- A. I am not a terrorist.
- B. Is it your feeling that I am trying to poison you?
- C. This is your medication, which you have to take now.
- D. I am a nurse from another unit in this hospital.
Correct Answer: B
Rationale: Reflecting the client’s feelings validates their emotions and opens therapeutic communication without confrontation, which is critical for a client with possible paranoia. Denying, insisting, or explaining may escalate distrust.
A client with schizophrenia states to the nurse, 'I am a spy for the FBI. I am an eye, an eye in the sky.' Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?
- A. Echolalia
- B. Word salad
- C. Clang associations
- D. Loosened associations
Correct Answer: C
Rationale: The repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern seen in clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the involuntary parrot-like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another. Loosened associations occur when the individual speaks with frequent changes of subject and when the content is only obliquely related.