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NurseDive Free Nursing Practice Question
A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?
A. "If you do not get out of bed, you will not receive your meal.".
Threatening the client by linking her ability to receive meals with getting out of bed is not a therapeutic approach. It may create a negative and punitive atmosphere, which is counterproductive when dealing with a client who is struggling with depression.
B. "I will help you get ready, and then you can rest after activities.".
This response demonstrates a balanced and empathetic approach. By offering assistance to the client in getting ready and then allowing her to rest after activities, the nurse is acknowledging the client's current state while gently encouraging her to engage in activities. This approach respects the client's autonomy while offering support.
C. "You should rest until you feel able to join the group.".
While suggesting that the client rest until she feels able to join the group acknowledges her need for rest, it might not provide the necessary encouragement to engage in therapeutic activities. This response could inadvertently reinforce avoidance behavior and hinder progress.
D. "You really need to follow the rules of the unit and get out of bed.".
Using language that emphasizes rules and regulations might be seen as dismissive and unhelpful. Depression is a complex mental health issue that requires understanding and therapeutic communication rather than a strict adherence to rules.
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
Similar Questions
A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?
A. "If you do not get out of bed, you will not receive your meal.".
Threatening the client by linking her ability to receive meals with getting out of bed is not a therapeutic approach. It may create a negative and punitive atmosphere, which is counterproductive when dealing with a client who is struggling with depression.
B. "I will help you get ready, and then you can rest after activities.".
This response demonstrates a balanced and empathetic approach. By offering assistance to the client in getting ready and then allowing her to rest after activities, the nurse is acknowledging the client's current state while gently encouraging her to engage in activities. This approach respects the client's autonomy while offering support.
C. "You should rest until you feel able to join the group.".
While suggesting that the client rest until she feels able to join the group acknowledges her need for rest, it might not provide the necessary encouragement to engage in therapeutic activities. This response could inadvertently reinforce avoidance behavior and hinder progress.
D. "You really need to follow the rules of the unit and get out of bed.".
Using language that emphasizes rules and regulations might be seen as dismissive and unhelpful. Depression is a complex mental health issue that requires understanding and therapeutic communication rather than a strict adherence to rules.
E. "You really need to follow the rules of the unit and get out of bed.".
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?
A. "The ritualistic behavior provides sexual satisfaction.".
The statement that "The ritualistic behavior provides sexual satisfaction" is incorrect. Ritualistic behaviors in OCD are primarily driven by the need to alleviate anxiety, not sexual satisfaction. These behaviors are often performed in an attempt to prevent or reduce distressing thoughts or fears, not for sexual gratification.
B. "The client performs ritualistic behavior to boost self-esteem.".
The statement that "The client performs ritualistic behavior to boost self-esteem" is also incorrect. OCD rituals are not typically performed to boost self-esteem. Instead, they are carried out to neutralize obsessive thoughts and to manage overwhelming anxiety associated with those thoughts.
C. "The ritualistic behavior temporarily relieves anxiety.".
The correct answer is "The ritualistic behavior temporarily relieves anxiety." Individuals with OCD engage in ritualistic behaviors as a way to reduce the anxiety caused by their obsessions. These behaviors are performed in a compulsive manner to counteract distressing thoughts or to prevent perceived harm. The relief obtained from performing these rituals is usually short-lived and reinforces the cycle of OCD.
D. "The client performs ritualistic behavior to decrease feelings of shame.".
The statement that "The client performs ritualistic behavior to decrease feelings of shame" is incorrect. While shame and guilt may be associated with OCD symptoms, the primary driving factor for performing ritualistic behaviors is the need to manage anxiety, not specifically to alleviate feelings of shame.
A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?
A. "Take the medication on an empty stomach.".
The statement "Take the medication on an empty stomach" is not accurate. Lithium is typically taken with meals or a snack to minimize gastrointestinal side effects and to enhance absorption. Taking it on an empty stomach can actually increase the likelihood of experiencing nausea and stomach discomfort.
B. "Notify your provider if you experience vomiting or diarrhea.".
The correct answer is "Notify your provider if you experience vomiting or diarrhea." This is an important instruction because vomiting or diarrhea can lead to dehydration and alter the levels of lithium in the bloodstream. Since lithium has a narrow therapeutic range, any significant changes in its concentration can be harmful.
C. "Decrease your fluid intake to 1 liter per day.".
The statement "Decrease your fluid intake to 1 liter per day" is incorrect. While it's important to maintain adequate hydration, restricting fluid intake to such a low amount is not appropriate and can lead to dehydration. Lithium can affect the body's water balance, so it's important for clients to drink an appropriate amount of fluids unless otherwise directed by their healthcare provider.
D. "You might produce extra saliva while taking this medication.".
The statement "You might produce extra saliva while taking this medication" is not relevant to the side effects of lithium. Increased salivation is not a commonly reported side effect of lithium. It's important for the nurse to provide accurate and relevant information to the client regarding potential side effects.