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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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A man diagnosed with alcohol dependence experiences his first relapse. During his AA meeting, another group member states, I relapsed three times, but now have been sober for 15 years. Which of Yaloms curative group factors does this illustrate?
- A. Imparting of information
- B. Instillation of hope
- C. Catharsis
- D. Universality
Correct Answer: B
Rationale: The correct answer is B: Instillation of hope. This statement by the group member provides hope by showing that despite relapses, long-term sobriety is achievable. This aligns with Yalom's curative group factor of instillation of hope, where group members inspire and motivate each other through their own successes. The other choices are incorrect because:
A: Imparting of information focuses on sharing knowledge, not personal experiences.
C: Catharsis involves the release of emotions, not necessarily about hope for the future.
D: Universality is about realizing shared experiences, not specifically about hope for recovery.
To promote self-reliance, how should a psychiatric nurse best conduct medication administration?
- A. Encourage clients to request their medications at the appropriate times.
- B. Refuse to administer medications unless clients request them at the appropriate times.
- C. Allow the clients to determine appropriate medication times.
- D. Take medications to the clients bedside at the appropriate times.
Correct Answer: A
Rationale: The correct answer is A because it promotes self-reliance by empowering clients to take responsibility for their own medication schedule. By encouraging clients to request their medications at the appropriate times, the nurse fosters autonomy and self-management.
Choice B is incorrect as it is too extreme and may compromise client safety by withholding medications based solely on client request. Choice C is incorrect as it puts the responsibility solely on the client without appropriate guidance from the nurse. Choice D is incorrect as it does not actively involve the client in the medication administration process.
Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse should associate this response with which neurotransmitter?
- A. Dopamine
- B. Serotonin
- C. Norepinephrine
Correct Answer: C
Rationale: The correct answer is C, Norepinephrine. During the fight-or-flight response, the sympathetic nervous system is activated, leading to the release of norepinephrine. Norepinephrine increases heart rate, blood pressure, and alertness, preparing the body to either fight or flee from a perceived threat. Dopamine (A) is more related to reward and pleasure. Serotonin (B) is involved in regulating mood and emotions. Cortisol (D) is a stress hormone, not a neurotransmitter involved in the fight-or-flight response.
A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?
- A. The client is placed in seclusion.
- B. The client is placed in a geriatric chair with tray.
- C. The client is placed in soft Posey restraints.
- D. The client is monitored by an ankle bracelet.
Correct Answer: D
Rationale: The correct answer is D - The client is monitored by an ankle bracelet. This option allows for monitoring and tracking the client's movements without physical restraint, promoting autonomy and freedom of movement. Seclusion (A) is restrictive and isolating. Placing the client in a geriatric chair with tray (B) limits mobility and can be degrading. Soft Posey restraints (C) restrict movement and can lead to physical and psychological harm. An ankle bracelet (D) is the least restrictive option as it allows for monitoring while still allowing the client some independence and mobility.