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
Explanation
A. While both schizophrenia and PTSD are mental health disorders, the priority in this context for a soldier with a history of combat exposure is to screen for conditions that commonly arise from traumatic experiences, such as PTSD and major depressive disorder.
B. PTSD and major depressive disorder can often co-occur, especially in individuals exposed to trauma. Given the soldier's history of combat exposure and PTSD diagnosis, screening for major depressive disorder is crucial due to its frequent association with PTSD and its potential severity.
C. Bipolar disorder may share some symptoms with PTSD, but given the context of returning from combat and the diagnosis of PTSD, the priority would be to focus on screening for
conditions more directly linked to trauma.
D. Dementia is less likely to be directly related to combat exposure in a returning soldier. While it's essential to assess the soldier's overall mental health, the immediate concern in this scenario would be mental health conditions more commonly associated with trauma.
Correct Answer is A
Explanation
A. This statement demonstrates the nurse's willingness to spend time with the patient to build rapport and trust, offering the nurse's presence and support.
B. This statement expresses hope but doesn't directly offer the nurse's presence or support.
C. This question encourages exploration of the patient's feelings but doesn't directly offer the nurse's presence.
D. This statement shares personal experiences but doesn't directly offer the nurse's presence or support.
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