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 therapeutic?

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

"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."

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

Answer and Explanation

The Correct Answer is A

a. "You feel that your mother does not want you to come back home?" This response uses reflection, a therapeutic communication technique, to encourage the client to express and explore their feelings further.
b. "It's quite common for clients to feel that way after a lengthy hospitalization." While this normalizes the client's feelings, it might dismiss the client's unique emotional experience and does not invite further exploration.
c. "Why don't you talk to your mother? You may find out she doesn't feel that way." This response provides a solution but does not address the client's current emotional state or encourage them to express their feelings.
d. "Your mother seems like an understanding person. I'll help you approach her." This response makes an assumption about the mother and shifts the focus away from the client’s feelings.

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Correct Answer is B

Explanation

a. Altered thought processes; call an emergency treatment team meeting. While altered thought processes are present, the urgent concern is the command hallucination directing the client to harm the psychiatrist. An emergency treatment team meeting may not provide the immediate intervention required.
b. Command hallucinations; warn the psychiatrist. This is correct because the client is experiencing command hallucinations that pose a direct threat to the psychiatrist. The nurse has a duty to warn the potential victim and ensure the safety of both the client and others.
c. Persecutory delusions; orient the client to reality. Persecutory delusions are present, but the immediate danger from the command hallucinations takes precedence. Orienting the client to reality does not address the urgent safety issue.
d. Magical thinking; administer an antipsychotic medication. Magical thinking is not the correct symptom here. Administering medication is part of treatment but does not address the immediate safety concern.

A. Diphenhydramine B. Ondansetron C. Lorazepam D. Haloperidol

Correct Answer is B

Explanation

a. Diphenhydramine: Diphenhydramine is an antihistamine that can also be used for its sedative properties to help calm an agitated client.
b. Ondansetron: Ondansetron is an antiemetic used to prevent nausea and vomiting, not for managing agitation or assaultive behavior. The nurse should question this order as it is not appropriate for the client's current symptoms.
c. Lorazepam: Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects, making it appropriate for calming an agitated client.
d. Haloperidol: Haloperidol is an antipsychotic medication commonly used to manage severe agitation and aggressive behavior.

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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 therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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