A client is readmitted to the substance use disorder program for the second time in 6 months for alcohol use disorder. On admission, the client tells the nurse, "I am so ashamed." What should the nurse reply?
"I really thought you would make it."
"Why did you start drinking again?"
"You have nothing to be ashamed of."
"Tell me what has happened since your last admission."
The Correct Answer is D
Choice A reason: The statement "I really thought you would make it" is a non-therapeutic response that inadvertently reinforces the client's sense of shame and failure by expressing disappointment. This response introduces the nurse's personal expectations and emotional reaction into the therapeutic encounter, which shifts focus from the client's needs to the nurse's feelings. It may deepen the client's sense of inadequacy and guilt, which are emotional states known to perpetuate the cycle of relapse and avoidance of treatment. Therapeutic communication in the context of substance use disorder requires non-judgmental, supportive engagement focused on the client's experience rather than the nurse's expectations.
Choice B reason: Asking "Why did you start drinking again?" is a confrontational and potentially judgmental question framed in a manner that may imply blame or deficiency in the client's willpower or decision-making. The use of "why" in this context may provoke defensiveness, increase shame, and discourage honest communication. Furthermore, this question presupposes that the client made a voluntary and fully informed choice to relapse, which does not account for the neurobiological mechanisms of addiction, including compulsive craving, impaired prefrontal executive function, and conditioned cue-triggered responses. This response is not consistent with motivational interviewing or therapeutic communication principles for substance use disorder management.
Choice C reason: While the statement "You have nothing to be ashamed of" is intended to be reassuring and reduce the client's shame, it is a form of false or premature reassurance that invalidates the client's expressed emotional experience. Telling the client that they have nothing to be ashamed of without exploring the underlying experience of shame may feel dismissive or superficial, particularly for a client who has been managing shame as part of their recovery journey. More therapeutically effective approaches acknowledge the client's feelings as valid while gently redirecting the conversation toward understanding and support rather than simply negating the emotion.
Choice D reason: Responding with "Tell me what has happened since your last admission" is the most therapeutically appropriate nursing response. This open-ended statement accomplishes multiple therapeutic goals simultaneously: it acknowledges the client's readmission without judgment or blame, invites the client to share their narrative in their own words, facilitates therapeutic alliance through active listening and genuine interest, and gathers clinically relevant information about the circumstances of relapse, which is essential for individualized treatment planning. This approach is consistent with motivational interviewing principles, which emphasize empathic, non-confrontational exploration of the client's experience to facilitate internal motivation for change.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Lecturing is a one-directional, didactic approach to communication that is particularly ineffective with clients diagnosed with antisocial personality disorder (ASPD). Individuals with ASPD characteristically exhibit pervasive disregard for rules and authority, lack of remorse, deceitfulness, and manipulative behavior. A lecturing approach tends to provoke power struggles, resentment, and non-compliance in this population, as it implies a hierarchical dynamic that clients with ASPD are likely to resist or exploit. Evidence-based nursing communication strategies for ASPD discourage moralistic or preachy approaches.
Choice B reason: Negotiation as a teaching strategy with clients diagnosed with ASPD is counterproductive because it inadvertently reinforces manipulative interpersonal dynamics. ASPD is characterized by a pervasive pattern of exploitation of others and disregard for social norms. Engaging in negotiation with such clients may be interpreted as flexibility in boundaries, which can be exploited. Consistent, firm, and clearly communicated boundaries are central to managing therapeutic relationships with clients with ASPD, and negotiation undermines the necessary therapeutic structure.
Choice C reason: A challenging approach, which involves directly confronting or questioning the client's statements or behaviors, is inappropriate for clients with ASPD. These individuals have low frustration tolerance and are prone to hostile or aggressive responses when they perceive a threat to their control or dominance. Challenging a client with ASPD may escalate agitation, provoke defensiveness, or stimulate manipulative countermeasures. Therapeutic communication guidelines for ASPD emphasize consistency, clear limit-setting, and avoiding emotional engagement in confrontational dynamics.
Choice D reason: A direct communication approach is the most therapeutically appropriate strategy for teaching clients with ASPD. Directness involves clear, concise, honest, and matter-of-fact communication without ambiguity, moralizing, or emotional appeal. Clients with ASPD respond best to clear statements about expectations, consequences, and information delivered in a factual and non-emotional manner. This approach minimizes opportunities for manipulation, reduces misinterpretation, establishes firm boundaries, and conveys mutual respect without encouraging power struggles. It is consistent with evidence-based psychiatric nursing guidelines for managing clients with Cluster B personality disorders.
Correct Answer is C
Explanation
Choice A reason: Histrionic personality disorder is classified under Cluster B personality disorders and is characterized by a pervasive pattern of excessive emotionality and attention-seeking behavior. Key features include discomfort in situations where one is not the center of attention, theatrical and exaggerated emotional expression, seductive or provocative behavior, rapidly shifting and shallow emotional states, and use of physical appearance to draw attention. While histrionic personality disorder shares some features with narcissistic personality disorder, it is not defined by grandiosity or a global lack of empathy. The primary motivation in HPD is the need for attention, not the need for admiration combined with a sense of entitlement and superiority.
Choice B reason: Schizoid personality disorder is a Cluster A disorder characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. Affected individuals typically prefer solitary activities, show little desire for close relationships including family, lack interest in sexual experiences, demonstrate emotional coldness and detachment, and appear indifferent to praise or criticism. The clinical picture is one of social withdrawal and emotional aloofness, with no component of grandiosity or inflated self-image. Schizoid personality disorder is diagnostically distinct from narcissistic personality disorder in both symptomatology and underlying interpersonal dynamics.
Choice C reason: Narcissistic personality disorder (NPD) is a Cluster B personality disorder formally defined in the DSM-5 by a pervasive pattern of grandiosity (either in fantasy or behavior), a persistent need for admiration, and a marked lack of empathy. Additional features include a sense of entitlement, exploitation of others, arrogance, envy of others or belief that others envy them, and preoccupation with fantasies of unlimited success, power, or beauty. The triad of grandiosity, need for admiration, and absence of empathy described in the question stem is the core diagnostic triad of NPD, making this the definitively correct answer.
Choice D reason: Obsessive-compulsive personality disorder (OCPD) is a Cluster C disorder characterized by a pervasive preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. Individuals with OCPD are devoted to work and productivity, rigid and inflexible about ethics and values, unable to delegate tasks, hoarding of objects, and prone to miserly spending. OCPD is distinct from OCD in that the behaviors are ego-syntonic. There is no pattern of grandiosity, entitlement, or empathy deficit in OCPD, clearly distinguishing it from narcissistic personality disorder.
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