A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me". Which response demonstrates therapeutic communication?
"You have everything to live fore."
"Why do you see yourself as a failure?"
"Feeling like this is all part of being depressed."
"You've been feeling like a failure for awhile?"
When the community health nurse visits a client at home, the client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this client?
"I see."
"Really?"
"You're having difficulty sleeping?"
"Sometimes, I have trouble sleeping too."
A client experiencing disturbed though processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
Using open-ended questions and silence.
Sharing personal preference regarding food choices.
Documenting reasons why the client does not want to eat.
Offering opinions about the necessity of adequate nutrition.
A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing?
Denial
Projection
Regression
Rationalization
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?
"Have you shared your feelings with your family?"
I think we should talk more about your anger with your family."
"You're feeling angry that your family continues to hope for you to be cured?"
"You are probably very depressed, which is understandable with such a diagnosis."
On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse anticipates which client behavior?
Fearfulness regarding treatment measures.
Anger and aggressiveness directed toward others.
An understanding of the pathology and symptoms of the diagnosis.
A willingness to participate in the planning of the care and treatment plan.
A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take INITIALLY?
Contact the client's health care provider (HCP).
Call the client's family to arrange for transportation.
Attempt to persuade the client to stay "for only a few more days."
Tell the client that leaving would likely result in an involuntary commitment.
When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?
Monitor closely for harm to self or others.
Assist in completing an application for admission.
Supply the client with written information about their mental illness.
Provide an opportunity for the family to discuss why they felt the admission was needed.
The nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task that is MOST appropriate for this phase?
Planning short- term goals.
Making appropriate referrals.
Developing realistic solutions.
Identifying expected outcomes.
The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the Most Appropriate nursing response?
"No, I won't tell anyone."
"I cannot promise to keep it a secret."
"It depends on what the secret is about."
"If you tell me the secret, I may need to document it."
The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.
Libel
Battery
Assault
Slander
False Imprisonment
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend as is seen at your clinic every week." Which is the MOST Appropriate nursing response?
"I cannot discuss any client situation with you."
"If you want to know about Carol,k you need to ask her yourself."
"Only because you're worried about a friend, I'll tell you that she is improving."
"Being her friend, you know she is having a difficult time and deserves her privacy."
The nurse in the mental health unit recognizes which as being therapeutic communication techniques?
Restating
Listening
Ask the client, "Why?"
Maintaining neutral responses
Providing acknowledgment and feedback
Giving advise and approval or disapproval.
A client being seen in the emergency department immediately after being sexually assaulted appears alm and controlled. The nurse analyzes this behavior as indicating which defense mechanism?
Intellectualization
A client's unresolved feelings related to loss would be MOST LIKELY observed during which phase of the therapeutic nurse-client relationship?
Trusting
Working
Orientation
Termination
The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship?
Exploring the client's ability to function.
Exploring the client's potential for self-harm.
Inquiring about the client's perception or appraisal of why the rescue was unsuccessful.
Inquiring about and examining the client's feelings for any that may block adaptive coping.
Which statement demonstrates the BEST understanding of the nurse's role regarding ensuring that each client's rights are respected?
"Autonomy is the fundamental right of each and every client."
"A client's rights are guaranteed by both state and federal laws."
"Being respectful and concerned will ensure that I'm attentive to my client's rights."
"Regardless of the client's condition, all nurses have the duty to respect client rights."
A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following response by the newly licensed nurse requires additional teaching regarding nonverbal communication?
Personal space
Posture
Eye contact
Intonation
A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." Th nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating?
Offering general leads
Summarizing
Focusing
A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication?
Offering advice
Reflecting meaning
Listening attentively
Giving information
A nurse is conducting therapy with several clients and their families. Effective communication with clients and families is based on
discussing in-depth topics with which the client feels comfortable.
using silence to avoid unpleasant or difficult topics.
attending to verbal and nonverbal behaviors.
requiring the client and family to ask for feedback.
When a family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response?
"I think your son is getting better. What have you noticed?"
"I'm sure everything will be okay. It just takes time to heal."
"I'm not sure what's wrong. Have you asked the doctor about your concerns?"
"I understand you're concerned. Let's discuss what concerns you specifically."
A nurse in a mental health facility is preparing to conduct a class with older adult clients on grief and loss. Choose the verbal or nonverbal communication needs the nurse should employ when working with older adult clients. Select all that apply.
Recognize that the client may require amplification.
Minimize distractions, and face the client when speaking.
Shout out at the client to ensure they can hear you.
Allow plenty of time for the client to respond.
When impaired communication is assessed, ask for input from caregivers or family to determine the extent of the deficits and how to best communicate.
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." Which of the following defense mechanisms is the client using?
Reaction formation
Displacement
Sublimation
A nurse is obtaining informed consent for a client who has just learned she must have a breast biopsy. The client is perspiring and pale, has a respiratory rate 30/min, and says, "I don't quite understand what you're trying to tell me." The nurse should assess the client's anxiety as which of the following?
Mild
Moderate
Severe
Panic
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client?
Reassure the client that everything will be okay.
Use a low-pitched voice and speak slowly.
Ignore the client's anxiety so that he/she will not be embarrassed.
Demonstrate a calm manner while using simple and clear language.
A nurse is caring for a client who has severe anxiety. Identify the nursing interventions that the nurse can use to assist the client who is experiencing a severe anxiety. Select all that apply.
Provide an environment that meets the physical and safety needs of the client. Remain with the client.
Provide a quiet environment with minimal stimulation.
Use medications and restraint, but only after less restrictive interventions have failed to decrease anxiety to safer levels.
Encourage gross motor activities, such as walking and other forms of exercise.
Explain to the patient that many people feel this way, that it will get better its only a matter of time.
Set limits by using firm, short, and simple statements. Repetition may be necessary.
Direct the client to acknowledge reality and focus on what is present in the environment.
