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The nurse is caring for a client diagnosed with bipolar disorder. During the morning assessment, the client tells the nurse that she hears people in the room behind her bed talking about her. Which response by the nurse best reflects therapeutic communication?
- A. What do you hear them saying?
- B. I will see if we can move you to another room.
- C. I will notify your doctor in case he wants to change your medications.
- D. I understand that the voices seem real to you, but I don't see or hear anyone else in here.
Correct Answer: D
Rationale: This response validates the client's experience without reinforcing the hallucination and promotes trust by acknowledging their perception.
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A client diagnosed with hyperaldosteronism has developed kidney failure and states to the nurse, 'This means that I will die very soon.' Which is the most appropriate therapeutic response for the nurse to make to the client?
- A. You will do just fine.
- B. What are you thinking about?
- C. You sound discouraged today.
- D. I read that death is a beautiful experience.
Correct Answer: B
Rationale: The therapeutic response encourages the client to express their thoughts and feelings about their prognosis, facilitating open communication. Option 1 provides false reassurance, which can block communication. Option 3 labels the client's emotions without encouraging further exploration. Option 4 is inappropriate and does not address the client's specific concerns about their condition.
A client was just told by the primary care primary health care provider that he will have an exercise stress test to evaluate his status after recent episodes of severe chest pain. As the nurse enters the examining room, the client states, 'Maybe I shouldn't bother going. I wonder if I should just take more medication instead.' Which therapeutic response should the nurse make to the client?
- A. Can you tell me more about how you're feeling?'
- B. Don't you really want to control your heart disease?'
- C. Most people tolerate the procedure well without any complications.'
- D. Don't worry. Emergency equipment is available if it should be needed.'
Correct Answer: A
Rationale: Anxiety and fear are often present before stress testing. The nurse should explore a client's feelings if concerns are expressed. Option 1 is open-ended and is the only choice that is phrased to engender trust and the sharing of concerns by the client. Eliminate options that are inappropriate statements and limit communication.
A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea-anxiety-dyspnea cycle?
- A. Guided imagery and limiting fluids
- B. Relaxation and breathing techniques
- C. Biofeedback and coughing techniques
- D. Distraction and increased dietary carbohydrates
Correct Answer: B
Rationale: Relaxation and breathing techniques are effective in interrupting the dyspnea-anxiety-dyspnea cycle by calming the client and improving respiratory efficiency. These techniques help reduce anxiety, which can exacerbate dyspnea, and promote controlled breathing to enhance oxygenation. Guided imagery may be helpful but limiting fluids is unrelated to managing dyspnea or anxiety. Biofeedback and coughing techniques are not primarily indicated for this cycle. Distraction and increased dietary carbohydrates do not directly address the cycle and may not provide immediate relief.
The nurse evaluates the client response to a 2-week trial of electroconvulsive therapy (ECT). Which data indicates to the nurse that treatment is successful?
- A. The client no longer experiences phobias and anxiety.
- B. The client no longer counts objects out loud.
- C. The client is no longer mute and withdrawn.
- D. The client no longer displays overreaction to events.
Correct Answer: C
Rationale: ECT is primarily used for severe depression or catatonia. A client no longer being mute and withdrawn indicates improved engagement and mood, suggesting successful treatment. Other options are less directly associated with ECT outcomes.
A client who experienced a myocardial infarction (MI) 4 days ago refuses to dangle at the bedside, saying, 'If my doctor tells me to do it, I will. Otherwise, I won't.' Which behavior should the nurse determine that the client is displaying?
- A. Anger
- B. Denial
- C. Depression
- D. Dependency
Correct Answer: D
Rationale: Clients may experience numerous emotional and behavioral responses after an MI. Dependency is one response that may be manifested by the client's refusal to perform any tasks or activities unless specifically approved by the primary health care provider. Although the client's statement may express anger to some degree, it most specifically addresses dependency. There are no data in the question to support denial or depression.