A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?

"Have you thought about taking a sleeping pill?”

"Your fatigue will pass, and everything will be just fine.”

"Do you have a family member who can assist you?”

"Let's discuss how to get you the help you need.”

Answer and Explanation

The Correct Answer is D

A. "Have you thought about taking a sleeping pill?”: While this response acknowledges the client's report of feeling tired, it immediately jumps to suggesting a specific solution without exploring the underlying reasons for the fatigue. It also assumes that medication is the appropriate intervention without further assessment.

B. "Your fatigue will pass, and everything will be just fine.”: This response minimizes the client's concerns and feelings by dismissing them with a vague reassurance. It does not validate the client's experience or offer practical support.

C. "Do you have a family member who can assist you?”: This response acknowledges the client's difficulty with grocery shopping and offers a practical solution by asking about available support from family members. It encourages the client to explore their support system and potential resources.

D. "Let's discuss how to get you the help you need.”: This response demonstrates empathy, validation, and a willingness to collaborate with the client to address their needs. It acknowledges the client's concerns and offers to explore solutions together, empowering the client to be actively involved in their care.

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Correct Answer is C

Explanation

A. Administer a sedative medication: While sedation may be necessary in some cases to manage acute agitation or aggression, it should not be the first action taken. Administration of sedative medication requires a careful assessment of the client's condition, potential drug interactions, and individualized dosing considerations. It's important to consider less restrictive interventions before resorting to sedation.

B. Perform a debriefing with the staff: Debriefing with the staff is an essential step in processing the crisis situation and ensuring the well-being of the team. However, it should not be the first action taken when the client is in immediate danger of harming themselves or others.

C. Acknowledge the client's emotions: Acknowledging the client's emotions and validating their feelings can help establish rapport and de-escalate the situation. However, if the client is actively threatening self-harm or violence, addressing safety concerns should take precedence.

D. Place the client in restraints: Restraints should only be used as a last resort and when less restrictive interventions have failed to ensure the safety of the client and others. Restraints should not be the first action taken, especially if there are other interventions that can be attempted to de-escalate the situation.

A. Weight gain and dry mouth B. Oliguria and muscle weakness C. Hallucinations and blurred vision D. Coarse hand tremors and confusion

Correct Answer is A

Explanation

A. Weight gain and dry mouth: Weight gain and dry mouth are common adverse effects of lithium at therapeutic levels. They are not immediately dangerous but can affect compliance with the medication regimen.

B. Oliguria (reduced urine output) and muscle weakness are more concerning symptoms. They can indicate potential toxicity, especially oliguria, which suggests possible renal impairment, a serious concern with lithium therapy.

C. Hallucinations and blurred vision are more severe and typically associated with lithium toxicity rather than therapeutic levels. They indicate a need for immediate medical attention.

D. Coarse hand tremors and confusion: Coarse hand tremors and confusion are signs of lithium toxicity. At therapeutic levels, fine hand tremors can occur, but coarse tremors and confusion suggest higher serum levels.These symptoms are associated with toxicity and require urgent medical evaluation.

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A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available. which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is planning to teach a client who is taking lithium. Which of the following should the nurse include in the teaching as adverse effects of therapeutic lithium level?

Correct Answer is A

Explanation

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