A nurse is caring for a client who refuses to attend group therapy. Which of the following statements should the nurse make?

"If I were you, I would go to a few therapy sessions to give them a try."

"One of my friends went to group therapy and they improved significantly."

"You have the right to refuse to attend group therapy."

"You should go to group therapy if you want to get better.

Answer and Explanation

The Correct Answer is C

A. "If I were you, I would go to a few therapy sessions to give them a try": This statement is not appropriate because it places the nurse's personal perspective onto the client, potentially pressuring them. It does not respect the client's autonomy in making their own decisions.

B. "One of my friends went to group therapy and they improved significantly": Sharing personal experiences can make the client feel uncomfortable and may not be relevant to their own situation. It can also create a sense of comparison, which is not helpful.

C. "You have the right to refuse to attend group therapy": This statement is respectful of the client's autonomy and acknowledges their right to make decisions about their care. It empowers the client and maintains their dignity while respecting their refusal.

D. "You should go to group therapy if you want to get better": This statement may feel coercive, as it implies that the client "should" attend therapy to improve. It might lead the client to feel guilty or pressured rather than supported in their choice.

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Correct Answer is C

Explanation

A. Document the client's behavior hourly on a flow sheet: While documentation is important, it is more frequent than hourly. Clients in restraints should be observed and documented on more frequently, usually every 15 minutes to ensure safety and assess the client's condition.

B. Request a PRN client prescription for restraints from the provider: Restraints require a specific order from the provider, not a PRN (as needed) prescription. The order must be obtained initially and renewed per the facility's policy, typically every 24 hours.

C. Observe the client's behavior once every 15 minutes: Clients in restraints must be closely monitored for safety and well-being. The nurse should assess the client’s condition, including physical and emotional status, every 15 minutes.

D. Remove the restraint when the client calmly follows commands: Restraints should only be removed under appropriate conditions as assessed by the nurse, and with a provider’s order when necessary. The client's behavior alone does not determine the removal of restraints.

A. Intellectualization B. Introjection C. Rationalization D. Repression

Correct Answer is C

Explanation

A. Intellectualization: Intellectualization involves using logic or reasoning to avoid emotional response to stress, but it is not the defense mechanism demonstrated here. The client is not using abstract thinking to avoid feelings but justifying behavior.

B. Introjection: Introjection involves internalizing the beliefs or values of others, which is not what is happening in this scenario. The client is not adopting someone else’s values but rationalizing their own actions.

C. Rationalization: Rationalization is the defense mechanism the client is using. The client is justifying their drinking as a way to cope with stress, making the behavior seem reasonable or acceptable even though it may be harmful.

D. Repression: Repression involves unconsciously blocking out uncomfortable thoughts or feelings, but the client is not denying their emotions or thoughts about stress. Instead, they are justifying their behavior, which aligns more with rationalization.

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A nurse is caring for a client who refuses to attend group therapy. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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