The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

A lot of clients behave that way, but you cannot take it personally.

Have you tried to establish a therapeutic relationship with the clients?

Do you want me to assign another nurse?

Clients often behave that way when they are in pain.

Answer and Explanation

The Correct Answer is B

Choice A reason:
While this response acknowledges the nurse’s feelings, it does not provide a constructive solution or address the underlying issue. It may come across as dismissive rather than supportive.

Choice B reason:
Establishing a therapeutic relationship is fundamental to effective nursing care. This response encourages the nurse to build rapport and trust with the clients, which can improve their engagement and cooperation in their care. It is a proactive and supportive suggestion.

Choice C reason:
Offering to assign another nurse does not address the issue of building a therapeutic relationship and may not be feasible. It also does not help the nurse develop skills to improve client interactions.

Choice D reason:
While clients in pain may exhibit disinterest, this response does not address the broader issue of establishing a therapeutic relationship. It focuses on a specific cause rather than providing a general strategy for improving client engagement.

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Correct Answer is D

Explanation

Choice A reason:
Assigning assistive personnel to feed the client at mealtimes is not typically necessary for clients with paranoid schizophrenia unless there are specific physical limitations. This intervention does not address the unique needs of managing paranoia and ensuring medication adherence.

Choice B reason:
Using touch to calm the client during periods of anxiety is not recommended for clients with paranoid schizophrenia. These clients may misinterpret touch as a threat, exacerbating their paranoia and anxiety.

Choice C reason:
Rotating staff assignments for this client can increase anxiety and paranoia. Consistency in caregivers helps build trust and reduces the client’s suspicion and anxiety.

Choice D reason:
Checking the client’s mouth after the client takes medication is crucial to ensure that the client has swallowed the medication. Clients with paranoid schizophrenia may hide or refuse medication due to their distrust, so this intervention helps ensure they receive their prescribed treatment.

A. THE 24-YEAR-OLD ONLY B. THE ENTIRE FAMILY C. THE 24-YEAR-OLD AND HIS MOTHER D. THE SISTER, MOTHER, AND 24-YEAR-OLD

Correct Answer is B

Explanation

Choice A reason:
The 24-year-old only being the client would imply that the therapy session is focused solely on the individual issues of the 24-year-old. However, the context of the therapy session, which includes multiple family members, suggests that the focus is on addressing family dynamics and conflicts. Family therapy typically involves working with the entire family unit to improve relationships and resolve conflicts, rather than focusing on a single individual.

Choice B reason:
The entire family being the client is the correct answer because family therapy aims to address issues within the family system as a whole. By involving the 24-year-old, his sister, his mother, and the mother’s live-in boyfriend, the therapy session is designed to explore and resolve conflicts that affect the entire family. This approach recognizes that individual issues are often interconnected with family dynamics, and addressing these dynamics can lead to more effective and lasting solutions.

Choice C reason:
The 24-year-old and his mother being the clients would limit the scope of the therapy to the relationship between these two individuals. While this might address some aspects of the family conflict, it would not provide a comprehensive approach to resolving issues that involve other family members, such as the sister and the mother’s live-in boyfriend. Family therapy is most effective when all relevant members are included in the process.

Choice D reason:
The sister, mother, and 24-year-old being the clients would exclude the mother’s live-in boyfriend, who is also part of the family dynamic. Excluding any family member who is involved in the conflict can limit the effectiveness of the therapy. Family therapy aims to include all relevant members to fully understand and address the issues affecting the family as a whole. Therefore, this option is not as comprehensive as involving the entire family.

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The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Correct Answer is D

Explanation

After experiencing increasing conflict in the home, a social worker calls and schedules a therapy meeting. A 24-year-old, his sister, his mother, and the mother’s live-in boyfriend are asked to attend the therapy meeting. Who is the “client” who will be treated during this session?

Correct Answer is B

Explanation

A nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply)

When communicating with a client, which would a nurse use to convey positive body language?

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?