A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me!" The nurse responds, "I understand, but it is time for group therapy and we expect everyone to attend. Let's walk over together." For which of the following reasons is the nurse's response considered therapeutic?
It demonstrates empathy towards the client.
It clearly articulates what is expected of the client.
It sets limits on the client's manipulative behavior.
It uses reflection when talking with the client.
The Correct Answer is B
A: Demonstrating empathy would involve acknowledging the client's feelings or beliefs, but the nurse does not validate the client's delusion or express understanding of the client's emotional state. Instead, the nurse redirects the client to the reality of the situation, which is the group therapy session.
B: The nurse's response is therapeutic because it clearly communicates the expectations of the therapy environment. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing clear, structured guidance without engaging with the delusion, which can help the client understand the reality of the situation and what is required of them.
C: Setting limits on manipulative behavior would involve addressing and curtailing attempts by the client to control or influence a situation for their own benefit. In this scenario, the client's behavior is delusional rather than manipulative, and the nurse's response does not directly set limits on manipulation but rather on adhering to the therapy schedule.
D: Using reflection would mean the nurse is mirroring the client's thoughts or feelings to help them self-reflect. However, the nurse does not reflect the client's statement but instead focuses on the expectations of the therapy program. The nurse's response does not encourage the client to reflect on their own thoughts or feelings but redirects them to the activity at hand.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. This response invalidates the patient's feelings and avoids addressing the emotion, hindering communication.
B. Acknowledging the patient's emotion validates their feelings and encourages further discussion.
C. Validates the patient's emotional expression and offers understanding.
D. Acknowledges the depth of the patient's pain and encourages expression without judgment.
Correct Answer is D
Explanation
A. Avoiding exposure to bright sunlight is not specifically related to SSRIs; it may be a
consideration with certain medications due to photosensitivity but isn't a primary concern with SSRIs.
B. Restricting sodium intake isn't a directive associated with SSRI antidepressant therapy.
C. Maintaining a tyramine-free diet is a concern with certain antidepressants like MAOIs (Monoamine Oxidase Inhibitors) but not typically with SSRIs.
D. Reporting increased suicidal thoughts is a crucial directive because SSRIs may initially increase the risk of suicidal ideation, especially in the early stages of treatment.
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