A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response.

I am worried about how much you are crying. Your grief over your husband's death has gone on too long

"The unexpected death of your husband must be very painful. I am glad you are able to talk to me about your feelings."

"Are you hearing voices at night?"

"This loss is harder to accept because of your mental illness. I will refer you to a partial hospitalization program."

Answer and Explanation

The Correct Answer is B

A. This response minimizes her grief and implies pathology; crying after a recent traumatic loss is normal.
B. This response acknowledges the client’s pain, validates her feelings, and encourages continued expression, making it therapeutic.
C. This abruptly changes the subject and ignores her grief, which is the client’s primary concern.
D. This pathologizes normal grief and focuses on her diagnosis instead of providing empathy and support.

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Correct Answer is D

Explanation

A. Occasional toileting accidents may be developmentally normal at age 3 and are not specific to autism spectrum disorder (ASD).

B. Interrupting or intruding on others is more consistent with ADHD than autism.

C. Crying when separated from a parent is typical of separation anxiety, not autism.

D. Repetitive motor behaviors such as rocking, hand-flapping, or spinning are characteristic of autism spectrum disorder. These stereotypical movements are used for self-stimulation and regulation.

A. "The most common side effects are directly related to the use of anesthesia." B. The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss." C. "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure." D. "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen."

Correct Answer is B

Explanation

A. While anesthesia is used, the side effects from it are not the main concern with ECT.
B. The most common side effects are mild confusion, headache, and short-term memory loss, which are typically temporary.
C. Muscle relaxants are given before the procedure to prevent cramping or injury from the seizure.
D. Myocardial infarction is not a common side effect; this response could unnecessarily alarm the spouse.

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A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response.

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