A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

Stop the car in the client's driveway and call the authorities.

Honk the car horn to get the client's attention.

Calmly speak the client's name out of the car window.

Keep driving in a path that is going away from the client's house.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.

Choice B reason:

Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.

Choice C reason:

Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.

Choice D reason:

Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.

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Correct Answer is B

Explanation

Choice A Reason:
This statement reflects an attempt to de-escalate a potential conflict by taking responsibility for an action that may have caused distress. However, it does not directly invite dialogue or understanding between family members. Effective communication in family therapy aims to foster open and empathetic dialogue, where members feel heard and understood.

Choice B Reason:
Asking for clarification on emotions connected to specific events is a hallmark of effective communication. This statement opens the door for the family member to share their feelings and for others to understand the perspective behind the emotions. It encourages a non-confrontational exchange of thoughts and feelings, which is essential in family therapy to promote healing and understanding.

Choice C Reason:
This statement is an example of a threat, which can lead to increased tension and conflict within the family. It is counterproductive to the goals of family therapy, which include improving communication and resolving conflicts in a constructive manner. Effective communication should be free of coercion and intimidation.

Choice D Reason:
While this statement may reflect a feeling or concern within the family dynamic, it is framed as an accusation rather than an invitation to discuss the behavior or its impact. Effective communication involves expressing one's own feelings and needs without making judgments about others' actions.

A. Provide sympathy during interactions. B. Focus on the words of the clients. C. Control the pace of establishing the nurse-client relationships. D. Demonstrate genuineness when communicating.

Correct Answer is D

Explanation

Choice A Reason:
Providing sympathy can be comforting, but it may not always be conducive to establishing a therapeutic relationship. Sympathy involves feeling pity for someone else's misfortune, which can sometimes create a power imbalance or imply that the nurse sees the client as unable to cope. In contrast, empathy, which is understanding and sharing the feelings of another, is more aligned with therapeutic communication principles.

Choice B Reason:
Focusing on the words of the clients is important, but it is only one aspect of communication. Therapeutic relationships are built on understanding the full context of communication, including non-verbal cues and emotional undertones. Active listening involves not just hearing words, but also interpreting the message being conveyed and responding appropriately.

Choice C Reason:
Controlling the pace of establishing nurse-client relationships might be necessary in certain situations, but it should not be the primary action. Each client is unique, and the development of a therapeutic relationship will vary depending on individual needs and circumstances. The nurse should be flexible and patient, allowing the relationship to develop naturally.

Choice D Reason:
Demonstrating genuineness when communicating is fundamental to building trust and rapport, which are essential components of a therapeutic relationship. Genuineness involves being open, honest, and sincere. When nurses are genuine, clients are more likely to feel respected and understood, leading to a stronger therapeutic alliance.

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A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is leading a group family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members?

Correct Answer is B

Explanation

A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement to establish therapeutic relationships with the clients?

Correct Answer is D

Explanation

A nurse overhears a client diagnosed with schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse should recognize the client's use of the word "flakala" as an example of which of the following alterations in speech?

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A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?

A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

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