A client on a psychiatric unit states, “It’s a waste of time being here. I can’t talk to you or anyone.” Which is the correct nursing response?

Our staff is excellent, and you are in good hands.

I think you should calm down and look at the positive side.

Are you feeling that no one understands?

I find that hard to believe.

Answer and Explanation

The Correct Answer is C

Choice A reason: Praising the staff dismisses the patient’s feelings, a nontherapeutic response. It fails to explore the patient’s sense of isolation, potentially worsening distrust, as it does not engage the emotional distress expressed, making this choice incorrect.

Choice B reason: Telling the patient to calm down and focus on positives minimizes their feelings, a nontherapeutic approach. It ignores the underlying emotional distress, potentially inhibiting therapeutic communication and trust, making this choice incorrect for the scenario.

Choice C reason: Reflecting the patient’s feeling of being misunderstood is therapeutic, as it validates their emotions and invites further exploration. This open-ended response engages the patient’s limbic system, fostering trust and emotional processing, making this the correct choice.

Choice D reason: Expressing disbelief invalidates the patient’s experience, a nontherapeutic response. It risks alienating the patient, hindering therapeutic alliance by dismissing their emotional distress rather than exploring it, making this choice incorrect.

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Correct Answer is D

Explanation

Choice A reason: Checking with the physician before releasing information to a legal guardian is unnecessary, as guardians have legal authority to access patient information. This response delays care coordination and disregards the guardian’s role, potentially hindering decision-making, making it incorrect.

Choice B reason: Requiring patient consent is inappropriate for a patient with advanced Alzheimer’s, who lacks decision-making capacity. The court-appointed guardian has legal authority to receive medical information, as they act in the patient’s best interest, making this response incorrect.

Choice C reason: Restricting information to immediate family ignores the legal guardian’s authority. Guardians, regardless of family status, are legally entitled to medical updates to make informed care decisions, as they represent the patient’s interests, making this response incorrect.

Choice D reason: Providing the guardian with medication and care plan updates is appropriate, as they have legal authority to make healthcare decisions for the patient. This ensures informed decision-making and complies with legal and ethical standards, making this the correct choice.

A. Do the voices come from the TV or the radio? B. Tell me more about what the voices say to you. C. Are the voices telling you to harm yourself or others? D. Do you hear the voices more during the day or night?

Correct Answer is B

Explanation

Choice A reason: Asking if voices come from external sources like TV assumes a delusional origin and closes off exploration. Open-ended questions are needed to assess the nature and impact of auditory hallucinations in schizophrenia, making this choice nontherapeutic.

Choice B reason: Asking the patient to describe the voices’ content is an open-ended response that encourages detailed disclosure. This helps assess the hallucinations’ nature, frequency, and impact on behavior, aiding in risk assessment and treatment planning, making this the correct choice.

Choice C reason: Asking about harm is a closed-ended question that assumes a specific risk, potentially limiting exploration of the hallucination’s full context. While safety is critical, open-ended questions better assess the patient’s experience initially, making this choice less appropriate.

Choice D reason: Asking about the timing of voices is closed-ended and limits the depth of assessment. Understanding the content and impact of hallucinations is more critical for schizophrenia management, as timing alone does not reveal risk or severity, making this choice incorrect.

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A client on a psychiatric unit states, “It’s a waste of time being here. I can’t talk to you or anyone.” Which is the correct nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An elderly patient with advanced Alzheimer’s disease is admitted to the unit. The nurse is informed that the patient has a court-appointed legal guardian. The guardian arrives and asks for information about the patient’s medications and plan of care. What is the nurse’s best response?

Correct Answer is D

Explanation

A patient diagnosed with schizophrenia tells the nurse, “I hear voices sometimes, but they don’t bother me.” Which of the following is the most appropriate open-ended response by the nurse to further assess the patient’s experience?

Correct Answer is B

Explanation

A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

The nurse is preparing to perform a psychosocial assessment on a patient. Which of the following should be included in the environment to promote an effective assessment? (Select all that apply)

A woman experiences deep sadness after the death of her “side-piece,” but she feels unable to openly mourn because their relationship was not recognized openly. The nurse identifies this as an example of:

What is waxy flexibility in psychiatric patients?

The nurse uses a variety of therapeutic communication skills when working with patients. Which of the following is a therapeutic goal that can be accomplished through the use of therapeutic communication?

A patient recently lost her spouse and says, “I don’t know how I’m going to live without him.” Which of the following responses by the nurse is nontherapeutic?

A nurse is caring for an elderly patient with advanced dementia who is unable to make healthcare decisions independently. The patient’s adult child has been appointed legal guardian. What is the nurse’s best action regarding the patient’s care decisions?

During a mental health assessment, a patient laughs manically while describing a recent loss of a loved one. The nurse recognizes this emotional expression as: