A young client diagnosed with major depressive disorder recently had their engagement broken off by their fiancé, who claimed the client was too fat and ugly.
During a one-on-one interaction with the nurse, the client says, “My fiancé is really wonderful and is not to blame for calling off the engagement.
I look awful and I’m not much good for anything.”. What is the most appropriate response by the nurse?
“Tell me how you felt when your fiancé broke up with you.”.
“Maybe the breakup was for the best.”.
“Do you think you are better off without your fiancé?”
“How could your fiancé be wonderful after saying those things to you?”
The Correct Answer is A
Choice A rationale
The nurse’s response, “Tell me how you felt when your fiancé broke up with you,” is the most therapeutic because it encourages the client to express feelings. This is a crucial step in the healing process. The nurse is using active listening skills and showing empathy, which can help build a therapeutic relationship with the client. It’s important for the nurse to provide a safe and nonjudgmental environment for the client to express feelings of sadness, anger, or guilt related to the breakup.
Choice B rationale
The response, “Maybe the breakup was for the best,” is not therapeutic because it minimizes the client’s feelings and experiences. It’s not the nurse’s place to make judgments or assumptions about the situation. The nurse should focus on the client’s feelings and provide support.
Choice C rationale
The response, “Do you think you are better off without your fiancé?” could be seen as leading or suggestive. It’s important for the nurse to remain neutral and not impose personal beliefs or opinions on the client.
Choice D rationale
The response, “How could your fiancé be wonderful after saying those things to you?” could be seen as confrontational and judgmental. It’s not the nurse’s role to judge the client’s relationships or experiences. The nurse should provide a supportive and understanding environment for the client to express feelings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
Step 1 is to determine the volume to administer. The order is for 1mg and Ativan is available in mg/mL. So, 1mg ÷ 1mg/mL = 1mL.
Therefore, you will administer 1mL.
Correct Answer is B
Explanation
Choice A rationale
While teaching the client techniques for coping with the mother’s anger might be helpful, it does not address the root cause of the problem. The mother’s anger and inappropriate responses could be due to frustration from not being able to hear properly.
Choice B rationale
The mother’s behavior of not responding when her back is turned and becoming increasingly angry could be signs of hearing loss. A hearing evaluation would help determine if this is the case and appropriate interventions can be put in place.
Choice C rationale
Telling the client that it appears the mother has a hearing loss is not the best intervention because it is based on assumption without any professional evaluation. It is important to have a professional evaluation before making such conclusions.
Choice D rationale
Informing the client to ignore the behavior and treat the mother with love does not address the potential issue of hearing loss. Ignoring the problem does not solve it and could lead to further frustration and misunderstanding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.