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Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations?
- A. My sister has the same diagnosis as you and she also hears voices.
- B. I understand that the voices seem real to you, but I do not hear any voices.
- C. Why not turn up the radio so that the voices are muted.
- D. I wouldnt worry about these voices. The medication will make them disappear.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation without reinforcing the hallucinations. By acknowledging the client's experience while maintaining reality orientation, the nurse can build trust and rapport. Choice A may unintentionally normalize the hallucinations. Choice C could dismiss the client's experience and avoid addressing the underlying issue. Choice D minimizes the client's distress and relies solely on medication without addressing the client's emotional needs.
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According to Eriksons developmental theory, when planning care for a 47-year-old client, which developmental task should a nurse identify as appropriate for this client?
- A. To achieve a sense of self-confidence and recognition from others
- B. To reflect back on life events to derive pleasure and meaning
- C. To achieve established life goals and consider the welfare of future generations
Correct Answer: B
Rationale: In Erikson's theory, the developmental task for a 47-year-old client aligns with the stage of Generativity vs. Stagnation. Choice B, reflecting on life events for pleasure and meaning, corresponds to this stage where individuals assess their accomplishments and seek fulfillment. This phase involves contributing to society and future generations. Choice A pertains to the earlier stage of Identity vs. Role Confusion in adolescence. Choice C aligns with the later stage of Integrity vs. Despair in older adulthood. Choice D is incomplete. Therefore, the correct answer is B as it best fits the age and developmental stage of the client in question.
During a therapeutic group, two clients engage in an angry verbal exchange. The nurse leader interrupts the exchange and excuses both of the clients from the group. The nurse has demonstrated which leadership style?
- A. Autocratic
- B. Democratic
- C. Laissez-faire
- D. Bureaucratic
Correct Answer: A
Rationale: The correct answer is A: Autocratic. This leadership style is characterized by making decisions independently and enforcing them without input from the group. In this scenario, the nurse leader interrupted the exchange and made the decision to excuse both clients without consulting the group. This approach is necessary in situations requiring immediate intervention to maintain order and ensure the safety of all group members.
Summary of other choices:
B: Democratic - In a democratic leadership style, decisions are made through group discussion and input from all members. This was not demonstrated in the scenario.
C: Laissez-faire - In a laissez-faire leadership style, the leader takes a hands-off approach and allows group members to make decisions. This was not demonstrated as the nurse leader took immediate action.
D: Bureaucratic - Bureaucratic leadership involves following strict rules and procedures. The scenario did not involve following predetermined rules but rather a quick decision made by the nurse leader.
A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: Perhaps this was the best thing to happen. Maybe Ill look into pursuing an art degree. How should the nurse characterize the clients appraisal of the job loss stressor?
- A. Irrelevant
- B. Harm/loss
- C. Threatening
- D. Challenging
Correct Answer: D
Rationale: The correct answer is D: Challenging. The client's statement indicates a positive reframing of the job loss as an opportunity for personal growth. This suggests that the client views the situation as a challenge to adapt and pursue a new path. This perspective aligns with the concept of stress as a potential source of growth and development, known as the challenge appraisal.
Summary:
A: Irrelevant - The client's statement demonstrates relevance to his future plans, making this choice incorrect.
B: Harm/loss - The client's positive outlook does not reflect a perception of harm or loss, making this choice incorrect.
C: Threatening - The client's statement does not convey a perception of threat, making this choice incorrect.
Which client statement may indicate a transference reaction?
- A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life.
- B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor.
- C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself.
- D. My mother is the source of my problems. She has always told me what to do and what to say.
Correct Answer: A
Rationale: Step 1: The client's statement "I need a real nurse" suggests a desire for a particular type of nurse, implying a transfer of feelings from a significant person onto the nurse.
Step 2: The client mentioning the nurse's age and relationship dynamics ("young enough to be my daughter") indicates projection of unresolved emotions onto the nurse.
Step 3: The client's reluctance to share personal information and discomfort with the nurse's perceived identity further supports the presence of transference reactions.
Summary: Option A is correct as it demonstrates transference by projecting emotions onto the nurse based on age and personal dynamics. Other choices lack clear indications of transference and focus on different issues like entitlement, social interaction difficulties, and blaming family members.
A client is trying to explore and solve a problem. Which nursing statement would be an example of verbalizing the implied?
- A. You seem to be motivated to change your behavior.
- B. How will these changes affect your family relationships?
- C. Why dont you make a list of the behaviors you need to change.
- D. The team recommends that you make only one behavioral change at a time.
Correct Answer: A
Rationale: Step 1: A is correct as it reflects active listening and shows empathy towards the client.
Step 2: By stating "You seem to be motivated to change your behavior," the nurse acknowledges the client's feelings and encourages further exploration.
Step 3: This statement helps the client feel understood and supported in their journey towards change.
Summary:
B: Focuses on family relationships, not the client's motivation.
C: Suggests a directive approach rather than exploring the client's feelings.
D: Imposes a specific recommendation without considering the client's readiness or motivation.