Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make?
A. "Your mood must be lifting because you have on clean clothes and have combed your hair.".
This makes an assumption about the client’s mood, which may not be accurate and can be interpreted as minimizing the client’s ongoing struggle.
B. "Oh, I'm so pleased that you finally put on clean clothes.".
This response might come across as condescending or patronizing, which can negatively impact the therapeutic relationship.
C. "I see that you have on clean clothes and have combed your hair.".
This response is an example of therapeutic communication that acknowledges the client’s actions without making assumptions or passing judgment. It is an observational statement that recognizes the client's effort, which can help to encourage further positive behavior without imposing interpretations on the client's motivations.
D. "Why did you wear clean clothes and comb your hair today?".
This could be interpreted as questioning the client's actions in a way that might make them feel defensive or uncomfortable.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Full Explanation
A. "Your mood must be lifting because you have on clean clothes and have combed your hair.": This makes an assumption about the client’s mood, which may not be accurate and can be interpreted as minimizing the client’s ongoing struggle.
B. "Oh, I'm so pleased that you finally put on clean clothes.": This response might come across as condescending or patronizing, which can negatively impact the therapeutic relationship.
C. "I see that you have on clean clothes and have combed your hair."This response is an example of therapeutic communication that acknowledges the client’s actions without making assumptions or passing judgment. It is an observational statement that recognizes the client's effort, which can help to encourage further positive behavior without imposing interpretations on the client's motivations.
D. "Why did you wear clean clothes and comb your hair today?": This could be interpreted as questioning the client's actions in a way that might make them feel defensive or uncomfortable.
Similar Questions
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
A. Ignore the client's behavior, realizing it is consistent with her illness.
Ignoring the client's disruptive behavior is not a suitable approach, as it could lead to a chaotic environment on the unit and potentially escalate the situation.
B. Set limits on the client's behavior and be consistent in approach.
Setting limits on the client's behavior is essential to maintain a therapeutic environment for all clients on the unit. Consistency in approach helps establish clear boundaries and expectations.
C. Ask the client to recommend consequences for her disruptive behavior.
Asking the client to recommend consequences for her disruptive behavior might not be appropriate, as it shifts the responsibility from the nursing staff to the client. Additionally, during a manic episode, the client's judgment might be impaired.
D. Warn the client that further disruptions will result in seclusion.
Warning the client about seclusion is an extreme measure that should be reserved for situations where the client's safety or the safety of others is at risk. It's important to start with less restrictive interventions, such as setting limits.
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?
A. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.".
In the denial phase of the grief process, individuals often use denial as a defense mechanism to cope with the overwhelming reality of their situation. This response reflects the client's disbelief in the doctor's prognosis, attributing it to an ulterior motive. The client's statement of exaggeration indicates their attempt to rationalize the situation, which is a characteristic of the denial phase.
B. "The doctor has been so good to me. I know he has tried everything he can. It is just my time.".
This response does not indicate denial but rather an acceptance of the situation and a recognition of the doctor's efforts. The client acknowledges that everything possible has been done and that it's their time to face the inevitable, which is not aligned with the denial phase.
C. "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.".
While lack of energy and motivation can be associated with the grief process, this response doesn't directly reflect denial. The focus here is on physical and emotional exhaustion rather than denial of the terminal diagnosis.
D. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer."
This response expresses frustration with the doctor's competence, but it doesn't reflect denial. The client's disbelief in the doctor's medical knowledge is a different coping mechanism rather than denial of their own situation.
An accomplished student has won an award and will need to accept the award as well as give a short speech to thank faculty. The student is fearful of public speaking. The student consults a nurse at the Student Health Center. The nurse is aware that social phobias are often treated using:.
A. Response prevention.
Response prevention is a therapeutic technique used in exposure and response prevention therapy for anxiety disorders, especially OCD. It involves intentionally refraining from performing compulsive behaviors in order to reduce anxiety. However, it's not the primary treatment for social phobias.
B. Modeling.
Modeling involves observing and imitating someone else's behavior to learn and acquire new skills. While it can be used in various therapeutic approaches, it's not the primary treatment for social phobias.
C. Meditation.
Meditation can be helpful for managing anxiety and stress, but it's not the primary treatment for social phobias. Meditation techniques are generally broader in application and may not specifically address the symptoms of social phobia.
D. Beta blockers.
Beta blockers are often used to manage the physical symptoms of anxiety, such as rapid heart rate, tremors, and sweating. They can be particularly helpful for situations where anxiety-related symptoms, like those associated with public speaking, need to be controlled quickly. Thus, beta blockers are commonly used to address social phobias and the anxiety associated with them.