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A nurse in a mental health facility is preparing to interview a client who has schizophrenia. Which of the following actions should the nurse take?
- A. Sit on the other side of a table from the client.
- B. Place the client in a chair higher than the nurse.
- C. Start the interview with a question the client can answer with “yes” or "no."
- D. Sit beside the client rather than facing him.
Correct Answer: C
Rationale: The correct answer is C: Start the interview with a question the client can answer with “yes” or "no." This approach is recommended for clients with schizophrenia to establish rapport and ease anxiety. It allows the client to engage in a simple way, reducing the pressure of providing complex answers. Sitting on the other side of a table (A) may create a barrier, placing the client in a higher chair (B) may be perceived as intimidating, and sitting beside the client (D) may invade personal space. The other choices do not promote effective communication or rapport-building.
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A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?
- A. Xenophobia
- B. Acrophobia
- C. Mysophobia
- D. Agoraphobia
Correct Answer: D
Rationale: Agoraphobia is the fear of being in open or public spaces, leading to avoidance behavior.
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. "My parents treat me like a baby sometimes."
- B. "I haven't gotten my period yet, and all my friends have theirs."
- C. "None of the kids at this school like me, and I don't like them either."
- D. "There's a big pimple on my face, and I worry that everyone will notice it."
Correct Answer: C
Rationale: The correct answer is C. The nurse's priority should be to address the adolescent's statement about not liking any kids at school and feeling disliked by others. This suggests potential social isolation, which can impact mental health and well-being. Addressing social relationships is crucial at this age for emotional development. Choices A, B, and D are important but not urgent concerns. Choice A relates to family dynamics, B to physical development, and D to self-image; while these are valid issues, they do not have immediate implications for the adolescent's well-being like the social isolation expressed in choice C.
A client awaiting surgery expresses fear of having cancer. Which response by the nurse is most appropriate?
- A. "Why do you think you have cancer?"
- B. "I don't see any reason for you to worry."
- C. "That's something to discuss with your provider."
- D. "I hear that you are concerned about this."
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the client's feelings and shows empathy. By saying, "I hear that you are concerned about this," the nurse validates the client's emotions and creates a supportive environment. Choice A is incorrect as it may come off as dismissive. Choice B is inappropriate as it invalidates the client's fear. Choice C passes the responsibility back to the client's provider instead of addressing the immediate concern.
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?
- A. "I will assist you in getting out of bed and getting dressed."
- B. "You can remain in bed until you feel well enough to join the group."
- C. "The unit rules state that you may not remain in bed."
- D. "If you don’t participate in your care, you will not get better."
Correct Answer: A
Rationale: Rationale: Choice A is correct because it demonstrates empathy, support, and encouragement. By offering assistance in getting out of bed and getting dressed, the nurse is promoting the client's self-care and well-being. This statement acknowledges the client's feelings while also providing the necessary support to engage in daily activities.
Incorrect Choices:
B: This choice enables the client's avoidance behavior and does not promote active participation in therapy or self-care.
C: This statement is authoritarian and does not address the client's emotional state or needs, which can worsen the client's depression.
D: This statement is negative and may induce guilt or shame in the client, which is counterproductive in supporting their mental health recovery.
A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me." The nurse responds, "I understand, but it is time for group therapy, and we expect everyone to attend. Let's walk over together.” For which of the following reasons is the nurse's response considered therapeutic?
- A. It clearly articulates what is expected of the client.
- B. It demonstrates empathy towards the delusion.
- C. It sets limits on the client's manipulative behavior.
- D. It uses reflection when talking with the client.
Correct Answer: A
Rationale: The correct answer is A because the nurse's response clearly articulates what is expected of the client, which helps maintain structure and promote accountability. By stating the expectation for the client to attend group therapy, the nurse is establishing boundaries and reinforcing the therapeutic environment. This approach helps the client understand the importance of participating in treatment activities.
Choice B is incorrect because empathy towards the delusion may validate the client's false beliefs, which is not therapeutic in this context. Choice C is incorrect as the response is not primarily aimed at setting limits on manipulative behavior but rather at promoting participation in therapy. Choice D is incorrect as the response does not involve reflection but rather straightforward communication of expectations.