A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?

Your mother seems like an understanding person. I’ll help you approach her.

It’s quite common for clients to feel that way after a lengthy hospitalization.

Why don’t you talk to your mother? You may find out she doesn’t feel that way.

You feel that your mother does not want you to come back home.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

While this response attempts to offer support, it makes an assumption about the mother’s understanding without addressing the client’s feelings directly. Therapeutic communication should focus on validating the client’s emotions and encouraging them to express their thoughts and feelings. This response might not fully acknowledge the client’s distress.

Choice B Reason:

This response normalizes the client’s feelings, which can be helpful, but it does not directly address the client’s specific concern. While it is important to reassure the client that their feelings are common, the response should also validate their individual experience and encourage further discussion.

Choice C Reason:

Encouraging the client to talk to their mother is a proactive suggestion, but it may not be the most therapeutic initial response. The client might not be ready to take that step, and the nurse should first focus on understanding and validating the client’s feelings before suggesting actions. This response could be more appropriate as a follow-up after the client’s feelings have been explored.

Choice D Reason:

This response is the most therapeutic because it uses reflective listening to validate the client’s feelings. By restating what the client has expressed, the nurse shows empathy and encourages the client to explore their emotions further. This technique helps the client feel heard and understood, which is crucial in therapeutic communication.

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Correct Answer is C

Explanation

Choice A Reason:

This response is inappropriate as it blurs the professional boundaries between the nurse and the client. Nurses are expected to maintain a professional relationship with their clients to ensure that care is provided in an ethical and unbiased manner. Suggesting a potential future relationship can lead to misunderstandings and compromise the therapeutic relationship.

Choice B Reason:

While this response correctly states hospital policy, it does not address the underlying issue of maintaining professional boundaries. It is important for the nurse to communicate the need for a professional relationship clearly and directly. Simply citing policy may not fully convey the importance of these boundaries to the client.

Choice C Reason:

This response is the most appropriate because it clearly establishes the professional nature of the nurse-client relationship. It helps the client understand that the nurse’s role is to provide care and support within a professional framework. This clarity is essential for maintaining trust and ensuring that the therapeutic relationship remains effective and ethical.

Choice D Reason:

Although this response sets a personal boundary, it does not address the professional aspect of the nurse-client relationship. The nurse’s marital status is irrelevant to the professional boundaries that need to be maintained. It is more important to emphasize the professional nature of the relationship rather than personal reasons for declining the request.

Correct Answer is ["0.5"]

Explanation

Step 1: Identify the available concentration of fentanyl.

The ampule contains 100 micrograms of fentanyl in 2 mL.

Step 2: Determine the dose required.

The nurse needs to give 25 micrograms of fentanyl.

Step 3: Calculate the volume (mL) needed for the required dose.

Use the formula: (Dose required ÷ Dose available) × Volume of available dose.

Step 4: Substitute the values into the formula.

(25 micrograms ÷ 100 micrograms) × 2 mL

Step 5: Perform the division.

25 micrograms ÷ 100 micrograms = 0.25

Step 6: Perform the multiplication.

0.25 × 2 mL = 0.5 mL

Result: The nurse will give 0.5 mL for the correct dose.

Final Answer: 0.5 mL

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A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

Correct Answer is C

Explanation

The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

Correct Answer is ["0.5"]

Explanation

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A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?