A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make?
"Your mood must be lifting because you have on clean clothes and have combed your hair.".
"Oh, I'm so pleased that you finally put on clean clothes.".
"I see that you have on clean clothes and have combed your hair.".
"Why did you wear clean clothes and comb your hair today?".
The Correct Answer is C
A. "Your mood must be lifting because you have on clean clothes and have combed your hair.": This makes an assumption about the client’s mood, which may not be accurate and can be interpreted as minimizing the client’s ongoing struggle.
B. "Oh, I'm so pleased that you finally put on clean clothes.": This response might come across as condescending or patronizing, which can negatively impact the therapeutic relationship.
C. "I see that you have on clean clothes and have combed your hair."This response is an example of therapeutic communication that acknowledges the client’s actions without making assumptions or passing judgment. It is an observational statement that recognizes the client's effort, which can help to encourage further positive behavior without imposing interpretations on the client's motivations.
D. "Why did you wear clean clothes and comb your hair today?": This could be interpreted as questioning the client's actions in a way that might make them feel defensive or uncomfortable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
No explanation
Correct Answer is C
Explanation
A.While it is important to understand changes in behavior, the sudden shift from depression to a cheerful state could be indicative of a potential risk, such as a plan to self-harm, particularly if the client is showing improved mood quickly.
B.It is not appropriate to reward a change in behavior without understanding the underlying reasons for the change. The sudden improvement in mood could be a sign of a potential risk, such as suicidal ideation or a temporary lift in mood before a possible crisis.
C.This is a crucial intervention. A sudden change in mood can sometimes be associated with an increased risk of self-harm or suicidal ideation, particularly if the client’s mood improves significantly before a more stable improvement in their depressive symptoms. Continuous monitoring helps ensure the client’s safety.
D.This could be premature and potentially unsafe, given the sudden and significant change in the client's condition. It is more important to ensure that the client’s mood change is not indicative of an underlying risk before allowing unsupervised activities.
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