A client in a manic episode is having difficulty concentrating and frequently changes topics during conversation. Which nursing response is appropriate in this situation?
"You're not making any sense right now. Can you focus?”
"I'm here to listen. Let's try to stick to one topic at a time.”
"Please stop interrupting and let others speak as well.”
"I don't understand what you're trying to say.”
The Correct Answer is B
Choice A rationale:
This response is not appropriate as it may come across as confrontational and dismissive of the client's current state. The client's difficulty in concentrating is a symptom of their manic episode, and using such phrasing might increase their agitation and escalate the situation.
Choice B rationale:
"I'm here to listen. Let's try to stick to one topic at a time." This response acknowledges the client's difficulty while providing support and a gentle redirection to stay focused on one topic. It maintains a therapeutic and non-confrontational approach, promoting effective communication with the client.
Choice C rationale:
While it's important to ensure fair participation in group conversations, this response may not address the immediate need of the client in a manic episode. It could potentially trigger further irritability or resistance from the client.
Choice D rationale:
This response may be interpreted as the nurse not making an effort to understand the client's thoughts, which could exacerbate the client's frustration and hinder therapeutic communication. It lacks empathy and a collaborative approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The correct answer is A, "The quality, intensity, range, and appropriateness of emotional expression." This choice reflects the comprehensive assessment of a patient's affect. The nurse should document aspects such as the quality (e.g., sad, angry, euphoric), intensity (e.g., blunted, intense), range (e.g., flat, labile), and appropriateness (e.g., congruent with the situation or not) of the patient's emotional expression.
Choice B rationale:
"Signs of flat, blunted, labile, or incongruent affect" are important to assess, but this choice is not as comprehensive as choice A. It focuses solely on specific features of affect without addressing the full spectrum of emotional expression.
Choice C rationale:
"The patient's thought content, such as themes, topics, and beliefs" is unrelated to assessing affect. Thought content pertains to the patient's cognitive processes and the content of their ideas, not their emotional expression.
Choice D rationale:
"Signs of flight of ideas, racing thoughts, tangentiality" pertain to thought processes, particularly in the context of assessing thought disorders like in bipolar disorder's manic phase. This is not directly related to the assessment of emotional expression.
Correct Answer is C
Explanation
Choice C rationale:
The primary goal of establishing a therapeutic nurse-patient relationship in the context of caring for a patient with MDD is to promote trust, rapport, empathy, and communication. This relationship provides a safe and supportive environment for the patient to express their thoughts and feelings, which is essential for effective treatment and recovery.
Choice A rationale:
Providing constant reassurance to the patient oversimplifies the therapeutic relationship. While offering reassurance is part of the nurse's role, the relationship is multidimensional and involves active listening, understanding, and collaborative problem-solving beyond just providing reassurance.
Choice B rationale:
Offering advice and solutions to the patient's problems might be part of the therapeutic process, but it's not the primary goal of the nurse-patient relationship. The relationship focuses on fostering open communication and empowering the patient to explore their feelings and thoughts.
Choice D rationale:
Encouraging the patient to rely solely on the nurse for support is not the goal of the therapeutic relationship. Instead, the nurse aims to empower the patient to develop a network of support and coping strategies, both within and outside the healthcare setting. This approach enhances the patient's long-term resilience.
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