Nokea
The nurse is trying to obtain some information about family relationships from the client. Which of the following statements is best?
- A. Is it upsetting for you to talk about your family?
- B. Is your family ready for you to come home?
- C. So, how is your family?
- D. Tell me your feelings about your family situation.
Correct Answer: D
Rationale: Asking the client to describe feelings about their family situation encourages open, detailed responses, unlike questions that may elicit brief or yes/no answers.
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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.
Which of the following are nontherapeutic techniques?
- A. Silence
- B. Voicing doubt
- C. Agreeing
- D. Challenging
- E. Giving approval
- F. Accepting
Correct Answer: C,D,E
Rationale: Agreeing, challenging, and giving approval are nontherapeutic as they can imply judgment or reinforce misconceptions, unlike silence, voicing doubt, or accepting, which support therapeutic dialogue.
Patient says to the nurse, 'I wonder what's playing at the movie tonight.' The most therapeutic response would be,
- A. Are you telling me you would like to go to the movies?
- B. Why don't you look in the newspaper.
- C. There's nothing worth watching.
- D. Do you like to go to the movies?
Correct Answer: A
Rationale: Verbalizing the implied clarifies the client's hint about wanting to go to the movies, making the conversation more direct and therapeutic.
Which of the following distance zones is acceptable for people who mutually desire personal contact?
- A. Social
- B. Intimate
- C. Personal
- D. Public
Correct Answer: B
Rationale: The intimate zone (0-18 inches) is suitable for those desiring personal contact, like close family, unlike social, personal, or public zones meant for other interactions.
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.