When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

“Mental illnesses do run in families, and I’ve had a lot of experience caring for people with mental illness.”

“Mental illness can be family related. Let’s focus the discussion on you and how you’re doing today.”

“It sounds like you are concerned that there may be a family connection to your current problem.”

“Yes, it does. I have a sister who was diagnosed several years ago with severe major depression.”

Answer and Explanation

The Correct Answer is D

Choice A reason:
This response provides general information about the hereditary nature of mental illnesses and reassures the client of the nurse’s experience. It maintains a professional boundary and does not disclose personal information, making it a therapeutic response.

Choice B reason:
This response acknowledges the client’s concern about the hereditary nature of mental illness and redirects the focus back to the client’s current situation. It is a therapeutic response that maintains professional boundaries and keeps the conversation client-centered.

Choice C reason:
This response validates the client’s concern and encourages further discussion about their feelings and experiences. It is a therapeutic response that promotes open communication and understanding.

Choice D reason:
Disclosing personal information about the nurse’s family can blur professional boundaries and shift the focus away from the client. It is considered nontherapeutic because it may make the client feel uncomfortable or distract from their own issues.

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Correct Answer is A

Explanation

Choice A reason:

“It is now time for you to bathe. Do you want to wear the red or green shirt?” This statement is therapeutic as it provides clear instructions and offers the client a choice, promoting autonomy and cooperation. It addresses the need for hygiene in a respectful and supportive manner.

Choice B reason:

“Do you really think it is okay not to bathe? What is going on with you?” This statement is confrontational and judgmental. It may make the client feel defensive or ashamed, which can hinder the therapeutic relationship and the client’s willingness to engage in self-care.

Choice C reason:

“This is it! You are getting a bath! There are three of us here to bathe you!” This statement is coercive and does not respect the client’s autonomy. Forcing the client to bathe without their consent can escalate the situation and damage trust between the client and the nurse.

Choice D reason:

“I’m going to ignore your lack of self-care because it is an aspect of the disorder.” Ignoring the client’s hygiene issues is not therapeutic. While it is important to understand that self-care deficits can be part of the disorder, the nurse should still address these issues in a supportive and respectful manner.

A. Assist the staff in caring for the client in a controlled environment B. Provide safety for the client and other clients on the unit C. Provide the clients on the unit with a sense of comfort and safety D. Offer the client a less stimulated area to calm down and gain control

Correct Answer is B

Explanation

Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.

Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.

Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.

Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.

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When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

Correct Answer is A

Explanation

During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

Correct Answer is B

Explanation

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

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