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A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time, and they are trying to poison my food." Which of the following statements should the nurse make?
- A. "You are mistaken. Nobody is lying about you or trying to poison you."
- B. "You seem to be having very frightening thoughts."
- C. "Why do you think you are being lied about and poisoned?"
- D. "Who is lying about you and trying to poison you?"
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without denying or confirming the delusions. It shows empathy and validates the client's experience without reinforcing the delusions. Option A is incorrect as it denies the client's beliefs, which can lead to distrust. Option C may encourage the client to provide more details about the delusions. Option D may inadvertently validate the delusions by asking for specific details.
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A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
- A. The sense of self among individual family members
- B. The future goals of the family
- C. The roles of family members
- D. The family's religious practices
Correct Answer: D
Rationale: The correct answer is D: The family's religious practices. When assessing sociocultural context, understanding the family's religious practices is essential as it influences beliefs, values, behaviors, and interactions within the family system. Religious practices can shape decision-making processes and coping strategies. A: The sense of self focuses on individual identity rather than the collective family system. B: Future goals pertain to the family's aspirations and plans, which are important but not directly related to sociocultural context. C: Roles of family members are significant in understanding family dynamics but do not capture the broader sociocultural influences.
A nurse is speaking with the parents of a 4-year-old child who has a terminal illness. The parents tell the nurse they have taken their son's name off the list for little league baseball next season. Which of the following responses should the nurse make?
- A. It must be frustrating for you to have to cancel an activity your son enjoyed.'
- B. Baseball can be a dangerous sport for children anyway.'
- C. You never know. He could be ready for baseball by the spring.'
- D. Why did you feel you needed to do that at this time?'
Correct Answer: A
Rationale: The correct answer is A: "It must be frustrating for you to have to cancel an activity your son enjoyed." This response shows empathy and acknowledges the parents' feelings without judgment. It validates their emotions and demonstrates understanding of their situation. Choice B is incorrect because it is dismissive and irrelevant to the parents' emotional state. Choice C is incorrect as it minimizes the parents' decision and disregards their current feelings. Choice D is incorrect as it may come off as confrontational and not empathetic towards the parents' emotions. The key is to show empathy and understanding towards the parents' situation, making choice A the most appropriate response.
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.
A nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility. The client asks the nurse why he has to go "to that place." Which of the following responses should the nurse make?
- A. "Your doctor feels that this is the best place for you right now."
- B. "Why don't you ask your doctor about that when she comes in to see you?"
- C. "Did your doctor or anyone else talk to you about going to the nursing home?"
- D. "Your family can't take care of you at home, so you will need to go there."
Correct Answer: C
Rationale: Encouraging discussion allows the client to express concerns and ensures they are informed about their care plan.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.