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. This statement is not necessarily accurate and could cause undue concern. Providers are not typically required to notify employers of a patient's admission to a mental health facility due to confidentiality regulations.
B. Informed consent for treatments, interventions, or medications is an ongoing process, and the client maintains this right even after admission to the facility. It's crucial to ensure the client
understands this.
C. While there are restrictions on leaving against medical advice (AMA) in some situations, the statement is too absolute. The client's ability to leave might depend on specific circumstances.
D. This statement is not entirely true. Even in an inpatient setting, patients generally have the right to refuse medications, although there might be discussions about treatment plans.
Correct Answer is C
Explanation
A. This is not the primary reason for the counseling. The decision-making recommendation is
more related to the effects of the electroconvulsive therapy and the need for the patient to recover from its associated side effects.
B. While readjustment to a work schedule might be a consideration, the primary reason for counseling against major decisions for a month is related to the potential side effects of
electroconvulsive therapy.
C. Temporary memory impairments and confusion are potential side effects of electroconvulsive therapy, which might interfere with decision-making abilities, hence the advice to refrain from major decisions.
D. Antidepressant medications causing confusion related to dietary limitations with tyramine is not directly relevant to the counseling against making major decisions after electroconvulsive therapy.
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