Which action should the nurse take prior to educating clients about relaxation techniques?

Assist the client to identify triggers or sources of stress.

Educate the client’s family so they can be active participants in the therapy.

Perform a physical assessment to ensure the client is able to participate in this therapy.

Obtain an order from the psychiatrist during the treatment team.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Assist the client to identify triggers or sources of stress.

This is the correct response. Before educating clients about relaxation techniques, it is essential to help them identify their specific triggers or sources of stress. Understanding what causes their stress allows for more tailored and effective relaxation strategies. This step ensures that the relaxation techniques taught are relevant and can directly address the client’s needs, leading to better outcomes in managing anxiety and stress.

Choice B Reason:

Educate the client’s family so they can be active participants in the therapy.

While involving the client’s family in therapy can be beneficial, it is not the primary action to take before educating the client about relaxation techniques. Family education can support the client’s overall treatment plan, but the initial focus should be on understanding the client’s individual stressors and needs.

Choice C Reason:

Perform a physical assessment to ensure the client is able to participate in this therapy.

Performing a physical assessment is important to ensure the client can safely participate in relaxation techniques. However, this step is secondary to identifying the client’s stress triggers. Once the triggers are identified, the nurse can then assess the client’s physical ability to engage in specific relaxation exercises.

Choice D Reason:

Obtain an order from the psychiatrist during the treatment team.

Obtaining an order from the psychiatrist may be necessary for certain interventions, but it is not typically required for teaching relaxation techniques. The nurse can independently educate clients on these techniques as part of standard nursing care for managing stress and anxiety.

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Correct Answer is C

Explanation

Choice A Reason:

Word salad.

Word salad refers to a jumble of words and phrases that lack logical coherence, often seen in severe cases of schizophrenia. The speech is typically incomprehensible and does not follow any recognizable pattern. In this case, the client’s response, while unusual, follows a pattern based on sound rather than meaning, which does not fit the definition of word salad.

Choice B Reason:

Loose association.

Loose association involves a series of thoughts that are only loosely connected to each other. This is a common symptom in schizophrenia, where the person’s thoughts may drift from one topic to another with little logical connection. However, the client’s response in this scenario is more structured and based on rhyming, which is characteristic of clang associations rather than loose associations.

Choice C Reason:

Clang association.

Clang association is a type of thought disorder where the person’s speech is governed by the sound of words rather than their meaning. This often results in rhyming or punning speech. The client’s response, “A match is a catch. A catch is a batch. The batch started to hatch,” is a clear example of clang association because the words are linked by their similar sounds rather than their meanings.

Choice D Reason:

Ideas of reference.

Ideas of reference involve the belief that ordinary events, objects, or behaviors of others have particular and unusual significance specifically for the person. This is often seen in paranoid schizophrenia. The client’s response does not indicate that they believe the words have special personal significance; instead, it shows a pattern of rhyming, which is more indicative of clang association.

A. “You should share this thought with your psychiatrist.” B. “I can make that promise to you based on nurse-client privilege.” C. “Those kinds of thoughts will make your hospitalization longer.” D. “I cannot promise that. Confidentiality does not include plans to hurt others.”

Correct Answer is D

Explanation

Choice A Reason:

“You should share this thought with your psychiatrist.”

This response suggests that the client should discuss their harmful thoughts with their psychiatrist. While it is important for the client to communicate openly with their mental health provider, this response does not directly address the nurse’s ethical and legal obligation to report threats of harm. The nurse has a duty to ensure the safety of others, and simply redirecting the client to another professional does not fulfill this responsibility. According to the Tarasoff rule, healthcare providers have a duty to warn potential victims if a client poses a credible threat.

Choice B Reason:

“I can make that promise to you based on nurse-client privilege.”

This statement is incorrect because nurse-client privilege does not extend to situations where there is a threat of harm to others. Confidentiality in healthcare is crucial, but it has limits, especially when it comes to preventing harm. Nurses are legally and ethically obligated to report any threats of violence or harm to appropriate authorities to protect potential victims. Making such a promise would be misleading and could result in serious consequences.

Choice C Reason:

“Those kinds of thoughts will make your hospitalization longer.”

This response is inappropriate as it focuses on the potential consequences for the client rather than addressing the immediate concern of a threat to another person’s safety. It may also discourage the client from being honest about their thoughts in the future. The primary responsibility of the nurse in this situation is to ensure the safety of the client and others, which involves reporting the threat to the appropriate authorities.

Choice D Reason:

“I cannot promise that. Confidentiality does not include plans to hurt others.”

This is the correct response. It clearly communicates to the client that while confidentiality is important, it does not cover plans to harm others. The nurse must explain that they are obligated to report any threats of violence to ensure the safety of potential victims. This response aligns with legal and ethical guidelines, which mandate that healthcare providers report credible threats of harm.

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Which action should the nurse take prior to educating clients about relaxation techniques?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client hears the word “match.” The client replies, “A match is a catch. A catch is a batch. The batch started to hatch.” Which communication pattern does the nurse identify?

Correct Answer is C

Explanation

A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?

Correct Answer is D

Explanation

A nurse working on a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. Which of the following are therapeutic communication techniques? (SELECT ALL THAT APPLY)

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A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?

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