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The client states to the nurse, 'I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What happens if something goes wrong after I go home?' Which statement by the nurse is the most therapeutic?
- A. Don't worry about the details. This procedure is done all the time and generally without any problems. You'll be fine!'
- B. They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I'll come.'
- C. Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can't be too careful.'
- D. You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?'
Correct Answer: D
Rationale: The client has verbalized concerns. In option 4, the nurse uses reflection to direct the client's feelings and concerns. In option 1 the nurse provides false reassurance and then minimizes the client's concerns. In option 2 the nurse is ventilating the nurse's own anger, frustration, and powerlessness. In addition, the nurse is trying to problem-solve for the client but is overly controlling and takes the decision making out of the client's hands. In option 3, the nurse is projecting the client's own fears, and the problem-solving suggested by the nurse will increase fear and anxiety in the client.
You may also like to solve these questions
According to psychodynamic theory, what purpose do delusions serve?
- A. Delusions are a defense against anxiety caused by real or imagined threats.
- B. Magical thinking is a delusion that ensures desirable outcomes.
- C. Delusions are a method of dealing with and interpreting external stimuli.
- D. Subconsciously, delusions are a way to safely express anger and hostility.
Correct Answer: A
Rationale: According to psychodynamic theory, delusions serve as a defense mechanism against anxiety triggered by real or perceived threats. Delusions are the individual's unconscious way of protecting themselves from overwhelming feelings of anxiety. Magical thinking, on the other hand, involves believing that one's thoughts can influence external events. This is not the same as delusions. Delusions are not a way of interpreting external stimuli but rather a defense mechanism. Expressing anger and hostility is typically associated with defense mechanisms like displacement or projection, not delusions.
Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?
- A. Touch
- B. Silence
- C. Focusing
- D. Summarizing
Correct Answer: C
Rationale: Focusing is the appropriate therapeutic technique to use when an anxious client exhibits pressured and rambling speech. By focusing on one specific aspect, the intended meaning is easier to understand and helps the client stay on track. Touch is not recommended in this scenario as it can invade the client's personal space and potentially increase anxiety. Silence may allow the client to continue rambling without addressing the underlying concerns. Summarizing requires the identification and exploration of the client's concerns, which may be challenging when the speech is pressured and disorganized.
The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client?
- A. Amoxicillin is an antibiotic that will help you get well.
- B. This medicine tastes just like fresh strawberries.
- C. You can't drink anything for an hour after taking this medicine.
- D. If you don't want to drink this medicine, I can give you a shot instead.
Correct Answer: A
Rationale: Informing the client that amoxicillin is an antibiotic that will help them recover provides age-appropriate education about the medication’s purpose, promoting understanding and adherence. Other options may mislead or unnecessarily alarm the child.
The nurse leads group therapy for clients diagnosed with substance abuse. A client diagnosed with alcoholism, and who occasionally uses marijuana and cocaine, attends the meeting. During the meeting the client states, 'I am having trouble sitting still. Am I bothering anybody? Maybe I should not come to these meetings.' Which action by the nurse is most appropriate?
- A. Encourage the client to share problems with the group.
- B. Remove the client from the group and further assess needs.
- C. Recognize this as manipulative behavior and encourage the client to remain in the group.
- D. Tell the other group members to ignore the client and continue with the group meeting.
Correct Answer: A
Rationale: Encouraging the client to share promotes engagement and allows the group to support them, addressing their restlessness therapeutically. Removing them isolates, labeling as manipulative is judgmental, and ignoring dismisses their needs.
What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?
- A. Feelings of guilt
- B. Need to control others
- C. Desire for punishment
- D. Excessive physical activity
Correct Answer: D
Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.