During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

Why are you concerned about these types of questions?"

"We can skip these questions, if you like. It isn't imperative that we complete this section."

"It is just a routine part of our assessment. All clients are asked these same questions."

Psychological factors like excessive stress have been found to affect medical conditions"

Answer and Explanation

The Correct Answer is D

a. "Why are you concerned about these types of questions?"
This response can seem confrontational and might increase the client's defensiveness.
b. "We can skip these questions, if you like. It isn't imperative that we complete this section."
Skipping the questions can lead to an incomplete assessment, and it does not address the client's concern.
c. "It is just a routine part of our assessment. All clients are asked these same questions."
While this is true, it does not explain the importance of the questions and may seem dismissive.
d. "Psychological factors like excessive stress have been found to affect medical conditions."
This response explains the rationale behind the questions and how they relate to the client's overall health, potentially helping the client understand the importance of a holistic assessment.

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Correct Answer is B

Explanation

a. "I may consider dating you once you have fully recovered." This response, while seemingly kind, is unprofessional. It creates a false sense of hope for the client and blurs the professional line.
b. "This is a professional relationship, and we need to be clear on that." This is a direct and professional way to set boundaries. It reminds the client of the nature of the relationship and avoids any misunderstanding.
c. "It's against hospital policy for me to date clients." While some hospitals might have such policies, this isn't always the case. A broader and more direct response like option b is preferable.
d. "I'm sorry, but I'm married and not interested in dating." This response might be true, but it focuses on the nurse's personal life and deflects from the professional aspect. Option b is more appropriate.

A. "I can see that you are upset. Let's talk about ways to resolve this." B. I'll fix this right away. You need to calm down." C. "Let's find a way to avoid this conflict in the future." D. "You should bring this up during group therapy later this week."

Correct Answer is A

Explanation

a. "I can see that you are upset. Let's talk about ways to resolve this." This is correct because it validates the client's feelings, encourages problem-solving, and maintains the therapeutic milieu's principles of respect and support.
b. "I'll fix this right away. You need to calm down." This response does not encourage the client’s participation in resolving the issue and does not foster the therapeutic milieu's goal of client empowerment.
c. "Let's find a way to avoid this conflict in the future." While this promotes future problem-solving, it does not address the immediate concern or validate the client's current feelings.
d. "You should bring this up during group therapy later this week." This delays addressing the client's immediate concerns and might make the client feel unheard.

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During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After having one conversation with a female nurse, a young male client asks the nurse for her phone number. He says that he would like to date her. Which of the following responses would be most appropriate?

Correct Answer is B

Explanation

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

Correct Answer is A

Explanation

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