Nokea
A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, 'I'm no good to anyone. I might as well be dead.' Which most therapeutic response should the nurse make to the client?
- A. You're not a useless person at all.'
- B. I'll ask the psychologist to see you about this.'
- C. You appear to be feeling pretty bad about things.'
- D. It makes me uncomfortable when you talk this way.'
Correct Answer: C
Rationale: Restating and reflecting keep the lines of communication open and encourage the client to expand on current feelings of unworthiness and loss that require exploration. The nurse can block communication by showing discomfort and disapproval or postponing the discussion of issues. Grief is a common reaction to a loss of function. The nurse facilitates grieving through open communication.
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When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?
- A. Listen to the parents' description of the child's behavior.
- B. Compare the child's function from one occasion to another.
- C. Engage the parents in a discussion about the child's feelings.
- D. Determine the child's mental status through direct questioning.
Correct Answer: B
Rationale: To accurately assess the mental status of a young school-aged child, it is crucial for the nurse to compare the child's function over time. This approach allows for a more objective evaluation of the child's mental status. While listening to the parents' description of the child's behavior can provide valuable insights, it may be biased and subjective. Engaging parents in discussions about the child's feelings is important for overall understanding but may not directly assess the child's mental status. Directly questioning the child about their mental status can be threatening and may lead to anxiety, making it a less optimal approach compared to observing and comparing the child's function over time.
A client diagnosed with Raynaud's disease tells the nurse that he has a stressful job and does not handle stressful situations well. Which life change should the nurse teach the client to consider to help alleviate his stress?
- A. Change to a less stressful job.
- B. Seek help from a psychologist.
- C. Consider a stress management program.
- D. Use earplugs to minimize environmental noise.
Correct Answer: C
Rationale: Stress can trigger the vasospasm that occurs with Raynaud's disease, so referral to a stress management program or the use of biofeedback training may be helpful. Option 1 is unrealistic. Option 2 is not necessarily required at this time. Option 4 does not specifically address the subject.
A client who has been on hemodialysis for 2 years communicates in an angry, critical manner and does not adhere to the prescribed medications and diet. Which explanation for the client's behavior would be useful to consider in planning care?
- A. An attempt to punish the nursing staff
- B. A constructive method of accepting reality
- C. A defense against underlying depression and fear
- D. An effort to maintain life and to live it as fully as possible
Correct Answer: C
Rationale: The client's angry, critical communication and non-adherence to treatment suggest underlying emotional struggles. The behavior is likely a defense mechanism against feelings of depression and fear. It is essential to consider that the client's actions are not intentionally aimed at punishing others but rather a manifestation of internal distress. Option A is incorrect as the behavior is not about punishing the nursing staff. Option B is incorrect because the behavior is not a constructive way of accepting reality but rather a maladaptive coping mechanism. Option D is incorrect as the behavior is not primarily driven by an effort to maintain life but rather by emotional distress.
A community health nurse visits a recently widowed retired military client. When the nurse visits, the ordinarily immaculate house is in chaos, and the client is disheveled and has an alcohol type of odor on his breath. Which therapeutic statement should the nurse make to the client?
- A. I can see this isn't a good time to visit.
- B. You seem to be having a very troubling time.
- C. Do you think your wife would want you to behave like this?
- D. What are you doing? How much are you drinking and for how long?
Correct Answer: B
Rationale: The therapeutic statement is the one that helps the client explore his situation and express his feelings. Reflection, by telling the client that the nurse feels that he is experiencing a troubled or difficult time, is empathic, and it will assist the client with beginning to ventilate his feelings. Option 1 uses humor to avoid therapeutic intimacy and effective problem-solving. Option 3 uses admonishment and tries to shame the client, which is not therapeutic or professional. This social communication belittles the client, will likely cause anger, and may evoke 'acting out' by the client. Option 4 uses social communication.
The spouse of a dying client states to the nurse, 'I don't think I can come anymore and watch her die. It's chewing me up too much!' Which is the most therapeutic response the nurse should make to the spouse?
- A. It's hard to watch someone you love die. You've been here with your wife every day. Are you taking any time for yourself?
- B. Focus on your wife's pain rather than yours. I know it's hard, but this isn't about what's happening to you, you know.
- C. I know it's hard for you, but she would know if you're not there, and you would feel so very guilty all of the rest of your days.
- D. I think you're making the right decision. Your wife knows you love her. You don't have to come every day. I'll take care of her.
Correct Answer: A
Rationale: The most therapeutic response is the one that is empathetic and that reflects the nurse's understanding of the client's, in this case, the husband's, stress and emotional pain. In the correct option, the nurse suggests that the client take time for himself. Option 2 is an example of a nontherapeutic and judgmental attitude that places blame. Option 3 makes statements that the nurse cannot know are true (the client's wife may not in fact know if the husband visits), and it predicts feelings of guilt, which is inappropriate. Option 4 fosters dependency and gives advice, which is nontherapeutic.