A nurse is interviewing a client who states, "I am at a total loss and don't know what to do anymore. I feel hopeless." Which of the following responses should the nurse make?
"If you do not like your medications, would you like to try an alternative?"
“You feel like you have no remaining options and are struggling to find a solution."
"Would you like to speak to a therapist after treatment?"
“You would like more information. I will get that for you right away."
The Correct Answer is B
A. "If you do not like your medications, would you like to try an alternative?" This response shifts focus away from the client's emotional state and does not validate their feelings.
B. "You feel like you have no remaining options and are struggling to find a solution." This response uses therapeutic communication by reflecting the client’s emotions, validating their feelings, and encouraging further discussion.
C. "Would you like to speak to a therapist after treatment?" While therapy may be beneficial, this response does not acknowledge the client's feelings in the present moment.
D. "You would like more information. I will get that for you right away." This response assumes the client is seeking information rather than expressing distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Not being chosen for a sports team: While disappointing, this is not considered an ACE because it does not involve abuse, neglect, or household dysfunction.
B. Experiencing physical abuse from a family member: Physical abuse is a recognized ACE, as it can lead to long-term psychological and physical health consequences.
C. Being teased by classmates : Bullying is harmful but is not classified as an ACE unless it involves severe abuse or trauma within the home.
D. Getting a low grade on a test: Poor academic performance is not considered an ACE unless it results from neglect, abuse, or extreme household dysfunction.
Correct Answer is A
Explanation
A. The client must be calm and cooperative. Restraints should be removed as soon as the client is calm and no longer poses a threat to themselves or others. Continued use without justification can be considered unethical and unlawful.
B. The client must verbalize remorse for their behavior. Remorse is not a requirement for restraint removal. Some clients may lack insight into their actions due to mental illness or cognitive impairment. The focus should be on safety, not forced expressions of regret.
C. The client only verbalizes anger toward the staff. Expressing anger alone is not a justification for continued restraint. As long as the client is not aggressive or violent, they should not remain restrained.
D. The provider who prescribed the restraints must be present to assess the client before the restraints can be removed. Nurses can remove restraints without the provider physically present if the client meets the criteria for release. However, they must document the assessment and notify the provider.
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