Nokea
During the mental status assessment, the client expresses the belief that the CIA is stalking him and plans to kidnap him. The best response by the nurse would be,
- A. That makes no sense at all.
- B. You can tell me about that after I finish asking these questions.
- C. What kinds of things have been happening?
- D. Why would the CIA be interested in you?
Correct Answer: C
Rationale: Seeking information encourages the client to elaborate on their belief, allowing the nurse to assess further without dismissing or reinforcing the delusion.
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A patient states, 'Right before I got here I was doing alright. My job was going well, my wife and I were happy, and we just moved into a new apartment.' The nurse responds, 'You said you and your wife were happy. Tell me more about that.' This is an example of which therapeutic technique?
- A. Encouraging comparison
- B. General lead
- C. Restating
- D. Exploring
Correct Answer: D
Rationale: Exploring delves deeper into a topic, like the client's happiness, to gain a fuller understanding, unlike restating or general leads which serve different purposes.
The nurse asks the client what that experience was like. Which communication skill is the nurse using?
- A. Encouraging expression
- B. Encouraging description of perceptions
- C. Exploring
- D. Requesting an explanation
Correct Answer: A
Rationale: Encouraging expression involves asking the client to describe the quality of their experience, as seen in the nurse's question about what the experience was like.
The nurse says to the client, 'You become very anxious when we start talking about your drinking.' Which of the following techniques is the nurse using?
- A. Confronting behavior
- B. Making an observation
- C. Translating into feelings
- D. Verbalizing the implied
Correct Answer: B
Rationale: Making an observation involves stating what the nurse sees, like the client's anxiety, allowing the client to validate or clarify without confrontation.
The nurse should use clear concrete messages when working with patients displaying which of the following conditions?
- A. Anxiety
- B. Anorexia
- C. Dementia
- D. Schizophrenia
- E. Hypochondriasis
Correct Answer: A,C,D
Rationale: Clear, concrete messages are essential for clients with anxiety, dementia, or schizophrenia, who may struggle with abstract thinking due to cognitive or emotional impairments.
Which of the following statements would be an empathetic response in a client interaction?
- A. You must have been embarrassed when your father yelled at you in the grocery store.
- B. You really should find your own housing and get out of the situation with your father.
- C. Well, it sounds like your father has difficulty controlling his temper.
- D. Why do you think your father chose that time and place to yell at you?
Correct Answer: A
Rationale: An empathetic response conveys understanding of the client's feelings, like embarrassment, without judgment or advice, as seen in the first option.