Nokea
The nurse is sitting down with a patient to begin a conversation. Which of the following positions should the nurse take to convey acceptance of the patient?
- A. Leaning forward with arms on the table sitting directly across for the patient
- B. Turned slightly to the side of the patients with arms folded across the chest
- C. Leaning back in the chair next to the patient with legs crossed at the knees
- D. Sitting upright facing the patient with both feet on the floor
Correct Answer: D
Rationale: An open, upright posture facing the client with feet on the floor conveys acceptance, unlike closed or casual postures that may signal defensiveness or disengagement.
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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.
A nurse has invited a patient to sit down and have a conversation. The patient takes the first seat. The nurse pulls up another chair to sit with the patient. Approximately how far from the patient should the nurse place her chair?
- A. 1 to 2 feet
- B. 3 to 4 feet
- C. 6 to 8 feet
- D. 8 to 10 feet
Correct Answer: B
Rationale: A distance of 3 to 6 feet is optimal for therapeutic communication, balancing comfort and professionalism, unlike closer intimate or farther social distances.
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.
Which of the following is the best reason that many psychiatric care units have policies against clients touching one another or staff?
- A. Because some clients with mental illness have difficulty knowing when touch is or is not appropriate
- B. Because clients often perceive being touched as a threat and may attempt to protect himself or herself by striking the staff person
- C. Because it can be threatening to both the client and the nurse
- D. Because touching always leads to more touching
Correct Answer: A
Rationale: Policies against touching in psychiatric units address clients' difficulty with understanding appropriate boundaries, reducing risks of misinterpretation or escalation.
A client has been making sexual comments when communicating with the nurse. The nurse wants to spend some time talking to the patient while respecting the patient's right to privacy. Which setting would be the most appropriate setting for the nurse to talk with the client?
- A. In the patient's room when the patient's roommate is present and 3 feet away
- B. At the nurse's station when other clients and visitors are less than 4 feet away
- C. In an interview room in a remote section of the unit with the nurse 1 foot away from the patient
- D. In a quiet corner of the dayroom at least 4 feet away from others
Correct Answer: D
Rationale: A quiet corner of the dayroom, at least 4 feet from others, balances privacy with safety, avoiding isolated settings or crowded areas that compromise confidentiality.