A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?
"Tell me about the visit with your significant other."
"Would you like to talk for a little while?"
"What did you enjoy about your visit tonight?"
"I can see that you are feeling lonely."
None
None
The Correct Answer is A
Choice A reason: This option is the most therapeutic because it is open-ended and invites the client to express feelings and experiences about the visit. By encouraging the client to talk, the nurse provides an opportunity for the client to explore emotions, which could explain why they became isolative afterward. Open-ended questions also demonstrate interest and support, which fosters trust and promotes communication in therapeutic relationships.
Choice B reason: Asking if the client would like to talk is supportive, but it is too vague and closed-ended. The client may simply answer “yes” or “no,” which does not facilitate deeper exploration of feelings. While it offers availability, it is not as therapeutic as directly encouraging discussion about the observed event, the visit.
Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.
Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.
Choice B reason: This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.
Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.
Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.
Correct Answer is D
Explanation
Choice A reason: Reviewing the chart for number of voids over the last 24 hours is not the best action to evaluate the client for urinary retention. It may provide some information about the client's urinary pattern, but it does not indicate the amount of urine left in the bladder after voiding.
Choice B reason: Palpating the suprapubic region for distention is a useful action to assess the client for urinary retention, but it is not the most accurate or reliable method. It may be difficult to palpate the bladder if the client is obese, has abdominal pain, or has bowel distention.
Choice C reason: Evaluating the client for urinary incontinence is not relevant to the assessment of urinary retention. Urinary incontinence is the involuntary loss of urine, while urinary retention is the inability to empty the bladder completely.
Choice D reason: Scanning the client's bladder after voiding is the best action to evaluate the client for urinary retention. It is a noninvasive and precise technique that measures the post-void residual urine volume. A normal post-void residual is less than 50 mL, while a high post-void residual indicates urinary retention.
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