Nokea
During the admission interview, the nurse asks the client what led to his hospitalization. The client responds, 'They lied about me. They said I murdered my mother. You're the killers. You all killed my mother. She died before I was born.' The best initial response by the nurse would be,
- A. I just saw your mother. She's fine.
- B. You're having very frightening thoughts.
- C. We'll put you in a private room until you're in better control.
- D. If your mother died before you were born, you wouldn't be here.
Correct Answer: B
Rationale: Verbalizing the implied acknowledges the client's frightening thoughts, validating their emotional experience without reinforcing delusions.
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The nurse is sitting with a patient who is crying. After a few minutes the nurse places one hand on the patient's shoulder. Which of the following best describes the purpose of the nurse's touch with this patient?
- A. To express sympathy to the patient
- B. To assess the patient's skin temperature and circulation status
- C. To offer comfort and support for the patient
- D. To extend an offer of friendship to the patient
Correct Answer: C
Rationale: Touch, when appropriate, offers comfort and support, not sympathy, physical assessment, or friendship, enhancing the therapeutic relationship.
Which of the following distance zones is acceptable for people who mutually desire personal contact?
- A. Social
- B. Intimate
- C. Personal
- D. Public
Correct Answer: B
Rationale: The intimate zone (0-18 inches) is suitable for those desiring personal contact, like close family, unlike social, personal, or public zones meant for other interactions.
The nurse is trying to obtain some information about family relationships from the client. Which of the following statements is best?
- A. Is it upsetting for you to talk about your family?
- B. Is your family ready for you to come home?
- C. So, how is your family?
- D. Tell me your feelings about your family situation.
Correct Answer: D
Rationale: Asking the client to describe feelings about their family situation encourages open, detailed responses, unlike questions that may elicit brief or yes/no answers.
Patient says to the nurse, 'I wonder what's playing at the movie tonight.' The most therapeutic response would be,
- A. Are you telling me you would like to go to the movies?
- B. Why don't you look in the newspaper.
- C. There's nothing worth watching.
- D. Do you like to go to the movies?
Correct Answer: A
Rationale: Verbalizing the implied clarifies the client's hint about wanting to go to the movies, making the conversation more direct and therapeutic.
A patient remarks, 'You know, it's the same thing every time.' The nurse should respond by stating,
- A. I understand
- B. I'm sure everyone is doing their best.
- C. I'm not sure what you mean. Please explain.
- D. It's the same thing every time?
Correct Answer: C
Rationale: Consensual validation seeks mutual understanding by clarifying ambiguous statements, ensuring both nurse and client share the same meaning.