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The nurse is caring for a client who says, 'I don't want to talk with you because you're only the nurse. I'll wait for my doctor.' Which statement should the nurse say in response to the client?
- A. I'm saddened by the way you dismissed me.
- B. I understand. So should I call your primary health care provider?
- C. Your primary health care provider directs me in your nursing care.
- D. So then, you would prefer to speak with your primary health care provider?
Correct Answer: B
Rationale: The nurse uses techniques of therapeutic communication to reflect the client's statement (option 2), redirect feelings back to the client for validation, and focus on the client's desire to talk with the doctor. Options 1 and 3 are nontherapeutic responses and are defensive responses. Option 4 reinforces the client's behavior and does not encourage client expression of feelings.
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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 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 is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the primary health care provider has prescribed?
- A. Psychodrama
- B. Reality therapy
- C. Psychoanalytic therapy
- D. Short-term dynamic psychotherapy
Correct Answer: A
Rationale: Psychodrama involves the enactment of emotionally charged situations. Reality therapy is used for individuals with cognitive impairment. Both short-term dynamic psychotherapy and psychoanalytic therapy depend on techniques that are drawn from psychoanalysis.
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.
A client who is quadriplegic frequently makes lewd sexual suggestions and uses profanity. The nurse concludes that the client is inappropriately using displacement. Which concern should the nurse identify as being appropriate for this client?
- A. Disuse syndrome
- B. Lack of coping skills
- C. Negative body image
- D. Lack of awareness of surroundings
Correct Answer: B
Rationale: Lack of coping skills is evident when the client demonstrates an impaired ability to adapt to meeting life's demands and roles. This client is displacing feelings onto the environment instead of using them in a constructive fashion. Option 3 may be appropriate, but it has nothing to do with the displacement that the client is currently using. Options 1 and 4 have no relation to this situation.