A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

"Why did you make the choice to behave negatively?”

"You need to calm down and forgive me before discussing this matter any further.”

"You were made aware of the consequences of negative behavior so you better go to your room.”

"I understand that you are angry. However, I followed the appropriate protocol.”

Answer and Explanation

The Correct Answer is D

Choice A rationale:

This response uses a confrontational tone and places blame on the client for their behavior, which is not an example of assertive communication. It can potentially escalate the situation and hinder effective communication.

Choice B rationale:

This statement is authoritarian in nature, using phrases like "you need to" and "forgive me," which can further upset the client and create a power struggle. It lacks empathy and understanding, making it ineffective for assertive communication.

Choice C rationale:

While this response acknowledges the consequences of the client's negative behavior, it uses commanding language ("you better go to your room"), which can be perceived as aggressive and may escalate the situation instead of facilitating effective communication.

Choice D rationale:

This statement is the most effective example of assertive communication. It acknowledges the client's feelings ("I understand that you are angry") while also asserting the nurse's adherence to protocol. This response demonstrates empathy, understanding, and a willingness to address the client's emotions in a non-confrontational manner.

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Correct Answer is A

Explanation

Choice A rationale:

Twisting tongue movements are characteristic manifestations of tardive dyskinesia (TD). TD is a movement disorder associated with long-term use of antipsychotic medications like fluphenazine (Prolixin). These involuntary movements often involve the face and tongue and can be irreversible if not addressed promptly.

Choice B rationale:

Constant tapping of feet when sitting is not a typical manifestation of tardive dyskinesia. This type of movement might be related to restlessness or anxiety, but it is not specifically associated with the movement disorder caused by prolonged antipsychotic use.

Choice C rationale:

Shuffling gait can be associated with parkinsonism, which is another potential adverse effect of antipsychotic medications, including fluphenazine. However, for tardive dyskinesia, the characteristic movements are more often related to the face and mouth rather than the legs and gait.

Choice D rationale:

Sudden onset of high fever is not a manifestation of tardive dyskinesia. It could potentially be a sign of a different medical issue, such as an infection. However, it is not directly related to the movement disorder caused by long-term antipsychotic use.

A. The partner has placed locks at the top of the doors leading to the outside. B. The partner redirects the client when the client is frustrated. C. The partner has hired a house cleaner. D. The partner has lost 25 lbs in the past 3 months.

Correct Answer is D

Explanation

The correct answer is choice D: "The partner has lost 25 lbs in the past 3 months."

Choice D rationale:

This choice is the correct answer because significant weight loss in a caregiver, such as the partner of a client with Alzheimer's disease, is indicative of caregiver role strain. Caregiver role strain refers to the physical, emotional, and psychological stress experienced by caregivers due to the demands of providing care for a loved one. Weight loss in this context suggests that the partner's own health and well-being are being compromised due to the caregiving responsibilities.

Choice A rationale:

This choice might be related to safety concerns and trying to prevent the client from wandering, but it does not directly indicate caregiver role strain. Placing locks at the top of doors is a common safety measure to prevent clients with Alzheimer's disease from wandering and getting lost.

Choice B rationale:

This choice is actually a positive observation. Redirecting a frustrated client is a helpful and appropriate caregiving strategy. It indicates that the partner is actively engaged in managing the client's behavior and emotions, which is not a sign of caregiver role strain.

Choice C rationale:

Hiring a house cleaner is a practical decision and could be a sign of the partner's effort to manage their caregiving responsibilities more effectively. While it might imply a certain level of stress, it doesn't directly point to caregiver role strain as much as the significant weight loss does.

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A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

Correct Answer is A

Explanation

A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

Correct Answer is D

Explanation

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