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 A
Explanation
The correct answer is Choice A.
When communicating with an angry patient, the nurse must first listen actively. Active listening allows the nurse to identify the key issues and work through them methodically.
Correct Answer is D
Explanation
Choice A rationale
Asking the client to make a verbal contract to not harm themselves is a common strategy used in suicide prevention. However, it is not the primary responsibility of the practical nurse in this scenario.
Choice B rationale
Returning the client to the waiting room with the spouse is not the most appropriate action. The client’s safety is the top priority, and they should be closely monitored due to their erratic behavior and expressions of despair.
Choice C rationale
Documenting that the client is not currently suicidal is important, but it is not the primary responsibility of the practical nurse in this scenario. The client’s non-verbal cues (shrugging their shoulders) suggest they may be at risk.
Choice D rationale
The primary responsibility of the practical nurse in this scenario would be to place the client in an ideal situation with one-on-one observation. This ensures the client’s safety and allows for immediate intervention if necessary.
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