What should the nurse do to establish trust in a therapeutic relationship with the clients?

Control the pace of establishing the nurse-client relationships.

Focus on the words of the clients.

Provide sympathy during interactions.

Demonstrate genuineness when communicating.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Controlling the pace of establishing nurse-client relationships is important, but it does not directly contribute to building trust. Trust is built on consistency and predictability, which can be fostered by controlling the pace, but it is the authenticity and transparency in interactions that lay the foundation for trust.

Choice B reason:

Focusing on the words of the clients shows attentiveness and respect for what they are saying, which is a component of active listening. While this is an essential skill for nurses, it is the understanding and empathetic response to those words that will build trust, not just the focus on the words themselves.

Choice C reason:

Providing sympathy during interactions can be comforting to clients, but sympathy alone may not establish trust. Sympathy is feeling compassion for someone else's situation, whereas empathy involves understanding and sharing the feelings of another. Empathy leads to deeper connections and trust than sympathy alone.

Choice D reason:

Demonstrating genuineness when communicating is the most effective way to establish trust. Genuineness involves being open, honest, and authentic with clients. It means the nurse is true to themselves and to the clients, which helps to create a safe space where clients feel understood and valued, leading to trust.

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Correct Answer is ["B","C","D","F"]

Explanation

Choice A: Set up a dietary consult for a low-sodium diet.

Reason: While a low-sodium diet is generally recommended for clients with heart failure to manage fluid retention and blood pressure, it is not the immediate priority in this scenario. The client’s current symptoms and lab results indicate lithium toxicity, which requires more urgent interventions.

Choice B: Notify the provider of potential medication interactions.

Reason: The client is taking lithium and furosemide, which can interact and increase the risk of lithium toxicity. Furosemide, a diuretic, can cause dehydration and electrolyte imbalances, exacerbating lithium toxicity. Notifying the provider is crucial to address these interactions and adjust medications accordingly.

Choice C: Withhold next dose of lithium.

Reason: The client’s lithium level is 2.2 mEq/L, which is above the therapeutic range (0.8 to 1.2 mEq/L) and indicates toxicity. Symptoms such as vomiting, diarrhea, muscle twitching, slurred speech, and drowsiness further support this. Withholding the next dose of lithium is necessary to prevent worsening toxicity2.

Choice D: Educate the client about the need for hemodialysis.

Reason: In cases of severe lithium toxicity, hemodialysis may be required to rapidly remove lithium from the body. Given the client’s high lithium level and symptoms, educating them about this potential treatment is important.

Choice E: Discuss contraception.

Reason: While discussing contraception is important for clients on lithium due to potential teratogenic effects, it is not an immediate priority in this acute situation. The focus should be on addressing the lithium toxicity and stabilizing the client.

Choice F: Assess need for and administer prochlorperazine PRN.

Reason: The client has been experiencing nausea and vomiting, which are symptoms of lithium toxicity2. Administering prochlorperazine can help manage these symptoms and provide relief. However, it is essential to monitor the client closely due to potential interactions with other medications.

A. "What are the voices telling you to do?" B. "You need to tell the voices to leave you alone." C. "You need to understand that there are no voices." D. "Why do you think you are hearing the voices?"

Correct Answer is A

Explanation

Choice A Reason:

The response "What are the voices telling you to do?" is appropriate because it allows the nurse to assess the content of the hallucinations and determine if there is an immediate risk of harm to the client or others. This approach shows empathy and concern for the client's experience while gathering crucial information to ensure safety. Understanding the nature of the voices can help the nurse provide appropriate interventions and support.

Choice B Reason:

Telling the client "You need to tell the voices to leave you alone" is not an effective response. This statement can be dismissive and may not acknowledge the client's distress. Clients with schizophrenia may not have the ability to control their hallucinations, and this response does not provide the necessary support or validation of their experience.

Choice C Reason:

The statement "You need to understand that there are no voices" is dismissive and invalidates the client's experience. Clients with schizophrenia perceive their hallucinations as real, and telling them that the voices do not exist can increase their distress and mistrust. It is important to acknowledge the client's experience while providing reassurance and support.

Choice D Reason:

Asking "Why do you think you are hearing the voices?" may not be helpful in the moment of acute distress. This question can be confusing and does not address the client's immediate fear and anxiety. The priority should be to assess the content of the hallucinations and ensure the client's safety rather than exploring the reasons behind the hallucinations.

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What should the nurse do to establish trust in a therapeutic relationship with the clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to the mental health unit. Exhibits The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["B","C","D","F"]

Explanation

Choice A: Set up a dietary consult for a low-sodium diet.

Choice B: Notify the provider of potential medication interactions.

Choice C: Withhold next dose of lithium.

Choice D: Educate the client about the need for hemodialysis.

Choice E: Discuss contraception.

Choice F: Assess need for and administer prochlorperazine PRN.

A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is caring for a client who reports stress related to homelessness. The nurse should identify that the client is experiencing which of the following types of stressors?

The nurse is asking a patient diagnosed with schizophrenia how they slept, and they respond, "This is a new day in May, and I can't wait to play." Which communication pattern does the nurse identify?

Which of the following findings should a nurse expect when assessing an adolescent female client with anorexia nervosa?

A nurse on a mental health unit observes a patient diagnosed with schizophrenia on antipsychotics exhibiting an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)

A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the highest priority for the nurse?

Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?