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A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?
- A. Notify the nurse manager
- B. Tell the nurse to stop discussing the behavior
- C. Provide an in-service program about confidentiality
- D. Complete an incident report
Correct Answer: B
Rationale: The correct action the nurse should take first in this situation is to tell the newly licensed nurse to stop discussing the client's hallucinations with another nurse. Maintaining client confidentiality is a critical aspect of nursing practice. By addressing the behavior immediately, the nurse helps prevent the inappropriate sharing of sensitive information about a client. Choice A is not the first action to take because addressing the behavior directly is more immediate and can prevent further breaches of confidentiality. Choice C is not the priority at this moment as immediate action is required to address the current situation. Choice D, completing an incident report, should come after addressing the immediate issue and ensuring that the inappropriate behavior ceases.
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When caring for a client with anorexia nervosa, which of the following examples demonstrates the nurse's use of interpersonal communication?
- A. The nurse discusses the client's weight loss during a health care team meeting
- B. The nurse examines their own personal feelings about clients with anorexia nervosa
- C. The nurse asks the client about their personal body image perception
- D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents
Correct Answer: C
Rationale: Interpersonal communication involves engaging in a conversation where the nurse asks the client about their personal body image perception. This demonstrates a direct interaction aimed at understanding the client's feelings and thoughts, which is essential in providing holistic care to individuals with anorexia nervosa. Choices A, B, and D do not directly involve the nurse-client interaction that characterizes interpersonal communication. A is more related to team communication, B focuses on the nurse's personal reflection, and D pertains to delivering educational content to a group rather than engaging in a one-on-one conversation with a client.
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention?
- A. Educating clients on health promotion techniques to reduce the risk of depression
- B. Performing screenings for depression at community health programs
- C. Establishing rehabilitation programs to decrease the effects of depression
- D. Providing support groups for clients at risk for depression
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is discussing free associations as a therapeutic tool with a nurse. Which of the following client statements indicates an understanding of this technique?
- A. "I will write down my dreams as soon as I wake up."
- B. "I might begin to associate my therapist with important people in my life."
- C. "I can learn to express myself in a nonaggressive manner."
- D. "I should say the first thing that comes to my mind."
Correct Answer: D
Rationale: Free association is a psychoanalytic technique where the client is encouraged to say the first thing that comes to their mind without censoring or filtering. This technique helps uncover unconscious thoughts and emotions. Choice D, "I should say the first thing that comes to my mind," indicates an understanding of free association as it aligns with the principle of allowing thoughts to flow freely without inhibition. Choices A, B, and C do not reflect an understanding of free association and its purpose, making them incorrect. A, focusing on writing down dreams, does not relate to the immediate expression of thoughts. B, associating the therapist with important people, and C, learning to express oneself nonaggressively, do not capture the essence of free association as a technique for exploring unconscious processes.
A client tells a nurse, 'Don't tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?
- A. Keep the client's communication confidential, but talk to the client daily using therapeutic communication to convince them to admit to hiding the knife
- B. Keep the client's communication confidential, but watch the client and their roommate closely
- C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others
- D. Report the incident to the health care team but do not inform the client of the intention to do so
Correct Answer: C
Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.
A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?
- A. Personal space
- B. Posture
- C. Eye contact
- D. Intonation
Correct Answer: D
Rationale: Verbal communication involves the use of words, tone, and pitch to convey messages. Intonation refers to the variation of pitch in speech, which can convey emotions, attitudes, and emphasize certain points. Therefore, intonation is a key component of verbal communication, making it the correct choice in this scenario. Choices A, B, and C are aspects of nonverbal communication. Personal space, posture, and eye contact are important nonverbal cues that contribute to effective communication, but they are not components of verbal communication.