A nurse works with a child who is sad and irritable because the child's parents are divorcing. Why is establishing a therapeutic alliance with this child a priority?

The child should express feelings rather than internalize them

Focusing on the strengths increases a person’s self-esteem

Acceptance and trust convey feelings of security to the child

Therapeutic relationships provide an outlet for tension

Answer and Explanation

The Correct Answer is C

Choice A reason: While expressing feelings is a healthy therapeutic goal, it is a secondary outcome of the relationship rather than the primary reason for the alliance itself. Without an initial foundation of safety, a child is unlikely to feel comfortable enough to externalize internalized emotions or process the trauma.

Choice B reason: Focusing on strengths is a component of a resilience-based approach and does help build self-esteem. However, in the context of a family crisis like divorce, the child's immediate psychological need is for a stable, secure attachment figure to mitigate the instability they are experiencing at home.

Choice C reason: For a child experiencing the instability of divorce, the world feels unpredictable. Establishing a therapeutic alliance based on acceptance and trust provides a "secure base." This perceived security is the essential prerequisite for all other therapeutic work, allowing the child to feel safe while navigating their changing environment.

Choice D reason: Providing an outlet for tension is a functional benefit of therapy, often achieved through play or talk. However, the "alliance" specifically refers to the bond between the nurse and patient. This bond's priority is to ensure the child feels emotionally held and safe during a period of upheaval.

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Correct Answer is A

Explanation

Choice A reason: When initiating SSRI therapy, there is a documented risk of increased suicidality, especially in children, adolescents, and young adults. As the medication begins to take effect, patients may regain enough physical energy to act on suicidal ideations before their mood significantly improves, necessitating close monitoring by family and clinicians.

Choice B reason: A tyramine-free diet is specifically required for patients taking Monoamine Oxidase Inhibitors (MAOIs), not SSRIs. Consuming high-tyramine foods like aged cheese or red wine while on MAOIs can trigger a hypertensive crisis. SSRIs do not interact with tyramine, so this dietary restriction is clinically unnecessary for this patient.

Choice C reason: Minimizing exposure to bright sunlight is a precaution typically associated with photosensitizing medications, such as certain antipsychotics (e.g., Chlorpromazine) or tetracycline antibiotics. While some patients may experience mild skin sensitivity, it is not a primary or priority teaching point for the standard administration of SSRI antidepressants.

Choice D reason: Restricting sodium intake to 1 gram daily is not indicated for SSRI therapy. In fact, SSRIs are occasionally associated with hyponatremia (low sodium levels), particularly in elderly patients, due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Therefore, aggressive sodium restriction could actually be counterproductive and dangerous.

A. Place the bed in the lowest position at bedtime B. Restrict fluid intake after 1800H C. Apply a PRN restraint at HS D. Ensure that all side rails are up at bedtime

Correct Answer is A

Explanation

Choice A reason: Placing the bed in the lowest position is a primary falls prevention strategy for patients with dementia. It minimizes the distance to the floor if the patient attempts to exit the bed unassisted, thereby reducing the impact and severity of potential injuries while maintaining the patient's dignity and autonomy.

Choice B reason: Restricting fluids after 1800H (6:00 PM) is generally discouraged as it can lead to dehydration and urinary tract infections in the elderly. While it might reduce nocturia, it does not address the underlying cognitive impairment causing the patient to wander or attempt to exit the bed during the night.

Choice C reason: The application of physical restraints, especially on a PRN (as needed) basis, is ethically and legally restricted. Restraints often increase agitation in patients with dementia and can lead to serious injuries or strangulation. They are considered a last resort and require specific, time-limited physician orders.

Choice D reason: Using four side rails is often classified as a form of physical restraint. For a patient with dementia, side rails can create a "caging" effect, leading the patient to attempt to climb over them. This significantly increases the risk of falling from a greater height, leading to more severe head or hip injuries.

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A nurse works with a child who is sad and irritable because the child's parents are divorcing. Why is establishing a therapeutic alliance with this child a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about which of the following?

Correct Answer is A

Explanation

Mr. Olsen, age 75 years, lives in a nursing home and is diagnosed with mild dementia. Occasionally he attempts to get out of bed during the night and is a risk for falls. What nursing intervention should the practical nurse use to ensure his safety?

Correct Answer is A

Explanation

Which finding best indicates that the goal "Demonstrates mentally healthy behaviour" was achieved?

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day. It has felt this way for a long while" The nurse documents this report as an example of which of the following?

A patient fearfully runs from chair to chair, crying, "They're coming! They're coming!" The patient does not follow the staffs directions or respond to verbal interventions. The initial nursing intervention of highest priority is to do which of the following?

Select the best question for the nurse to ask to help her assess a family's ability to cope?

During a psychiatric assessment, the nurse observes a patient’s facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood?

A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to which of the following?

An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?