The client says, "My marriage is just great.
My spouse and I always agree.”. The nurse observes the client's foot moving continuously as the client twirls a shirt button.
What conclusion can the nurse draw about the client's statement?
It is inadequate.
It is inconsistent.
It is clear.
It may be distorted.
The Correct Answer is B
Choice A rationale
Inadequacy pertains to a lack of sufficiency or quality regarding a statement's content or detail to convey a full idea. While the statement "My marriage is just great. My spouse and I always agree" might lack depth, the primary concern is the disparity between the verbal and non-verbal communication, suggesting internal conflict, rather than mere insufficiency of descriptive detail. The non-verbal cues overshadow content.
Choice B rationale
Inconsistency describes a conflict between different elements of communication, specifically here the spoken word and the observed body language. The client's verbal declaration of perfect agreement contrasts sharply with the continuous, agitated non-verbal behaviors (foot movement, button twirling), indicating underlying anxiety, psychological distress, or internal tension that contradicts the seemingly idyllic verbal message. This non-verbal leakage suggests the statement is not truthful.
Choice C rationale
Clarity refers to the ease of understanding the manifest content of the verbal message. The client's statement about the marriage being "just great" and always agreeing is grammatically clear and easily understood at a literal level. However, the nurse's observation of the non-verbal behavior suggests that the meaning or truthfulness of the statement is compromised by internal conflict.
Choice D rationale
Distortion implies a misrepresentation or alteration of reality, potentially stemming from a cognitive process or defense mechanism. While the client might be distorting the truth of their marriage, the nurse's direct observation reveals an immediate, simultaneous inconsistency between the two forms of communication, making inconsistency the more direct and observable conclusion regarding the communication dynamic itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Rapid, pressured speech, or tachylalia, is a common behavioral manifestation of mania, indicating an accelerated thought process known as a flight of ideas. While it affects communication and social interaction, it is a safety or security need concern (difficulty following rules, potential for anger) or a psychological need, ranking lower than physiological needs in Maslow's Hierarchy.
Choice B rationale
Hyperactive behavior reflects a state of psychomotor agitation and increased energy characteristic of mania, often leading to impulsive or non-goal-directed actions. This is primarily a safety and security need concern due to the risk of accidental injury or harm to self or others, placing it below the fundamental physiological needs in Maslow's hierarchy.
Choice C rationale
Lack of sleep, or insomnia, is a disruption of a fundamental physiological need essential for maintaining homeostasis, physical health, and cognitive function. According to Maslow's Hierarchy of Needs, physiological needs (like sleep, food, water, and breathing) must be met first, making this symptom the highest priority for intervention.
Choice D rationale
Grandiose thoughts are an alteration in thought content, reflecting an inflated sense of self-worth, power, or identity common in mania. This symptom relates to the need for self-esteem or self-actualization in Maslow's model, which are higher-level psychological needs, thus having a lower priority than the client's basic physiological needs.
Correct Answer is D
Explanation
Choice A rationale
While improved language use (e.g., fluency, confidence) is a necessary component for resolving the underlying reason for the social withdrawal, an outcome should be a measurable behavioral change or demonstrable action. Improving language skills is an antecedent step or a parallel goal, not the direct, observable behavioral goal of "Impaired social interaction.”.
Choice B rationale
Increased independence in decision making is a worthy goal related to autonomy, but it does not directly address the social interaction component of the nursing diagnosis. The core problem identified is the lack of participation in group settings due to the stated sociocultural conflict, requiring an outcome focused on behavioral engagement.
Choice C rationale
Improved social skills is a broad concept; the client's stated issue is a specific linguistic barrier, not necessarily a deficit in general social etiquette or reciprocal conversation skills. A behavioral outcome must be highly specific and directly linked to the evidence (not participating due to language difficulty) provided in the nursing diagnosis.
Choice D rationale
This outcome is the most measurable and directly addresses the impaired social interaction evidenced by non-participation. Selecting and participating in one group activity per day is a clear, time-bound behavioral goal that requires the client to overcome the stated barrier and engage in the desired social action.
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