A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?
"Would you like to talk for a little while?"
"I can see that you are feeling lonely."
"Tell me about the visit with your significant other."
"What did you enjoy about your visit tonight?"
The Correct Answer is A
Choice A Reason: This is correct because this response invites the client to express her feelings and thoughts without imposing any assumptions or judgments. It also conveys empathy and respect for the client's autonomy.
Choice B Reason: This is incorrect because this response makes an inference about the client's emotional state without validating it with her. It also may sound patronizing or pitying, which can hinder rapport.
Choice C Reason: This is incorrect because this response may be perceived as intrusive or prying, especially if the client is not ready or willing to share details about her personal relationship. It also may trigger negative emotions or memories that can worsen her mood.
Choice D Reason: This is incorrect because this response may be seen as superficial or irrelevant, especially if the client did not enjoy her visit or had a conflict with her significant other. It also may imply that the nurse is avoiding or dismissing the client's current feelings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.
Choice B Reason: This is correct because 60degrees is not fully upright and may not provide optimal protection against aspiration. The client should ideally be positioned at 90 degrees during meals if tolerated indicating need for additional teaching
Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.
Choice D Reason: This is incorrect because resting before meals decreases fatigue and improves swallowing ability.
Correct Answer is A
Explanation
Choice A Reason: This is correct because beginning with questions that are less sensitive in nature can help establish rapport and trust with the client, and make the client more comfortable and willing to disclose personal information.
Choice B Reason: This is incorrect because asking questions in a vague, non-specific format can confuse the client and lead to inaccurate or incomplete data. The nurse should ask clear, direct, and open-ended questions that elicit relevant information.
Choice C Reason: This is incorrect because getting the most difficult questions over with first can make the client feel anxious, embarrassed, or defensive, and discourage further communication. The nurse should build up to the more sensitive questions gradually and respectfully.
Choice D Reason: This is incorrect because sharing personal values to put the client at ease can be inappropriate and unprofessional, as it may impose the nurse's beliefs or opinions on the client or create bias or judgment. The nurse should maintain a neutral and objective attitude and respect the client's values.

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