A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me!" The nurse responds, "I understand, but it is time for group therapy and we expect everyone to attend. Let's walk over together." For which of the following reasons is the nurse's response considered therapeutic?
It demonstrates empathy towards the client.
It clearly articulates what is expected of the client.
It sets limits on the client's manipulative behavior.
It uses reflection when talking with the client.
The Correct Answer is B
A: Demonstrating empathy would involve acknowledging the client's feelings or beliefs, but the nurse does not validate the client's delusion or express understanding of the client's emotional state. Instead, the nurse redirects the client to the reality of the situation, which is the group therapy session.
B: The nurse's response is therapeutic because it clearly communicates the expectations of the therapy environment. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing clear, structured guidance without engaging with the delusion, which can help the client understand the reality of the situation and what is required of them.
C: Setting limits on manipulative behavior would involve addressing and curtailing attempts by the client to control or influence a situation for their own benefit. In this scenario, the client's behavior is delusional rather than manipulative, and the nurse's response does not directly set limits on manipulation but rather on adhering to the therapy schedule.
D: Using reflection would mean the nurse is mirroring the client's thoughts or feelings to help them self-reflect. However, the nurse does not reflect the client's statement but instead focuses on the expectations of the therapy program. The nurse's response does not encourage the client to reflect on their own thoughts or feelings but redirects them to the activity at hand.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Restraining the client should be a last resort and is not the initial action to take when managing an agitated client.
B. Seclusion should also be considered as a last resort, and de-escalation techniques should be attempted before secluding the client.
C. Speaking calmly and providing simple directions can help de-escalate the situation by promoting a calm environment and reducing stimuli that may exacerbate the client's agitation.
D. While medication might be necessary in some cases, it's not the first action to take when a client becomes agitated.
Correct Answer is C
Explanation
A. Contains foods high in tyramine like avocado, ham, and chocolate cake.
B. Includes smoked sausage and yeast rolls which are high in tyramine
C. This meal consists of foods typically low in tyramine content, suitable for a tyramine- restricted diet.
D. Macaroni and cheese, hot dogs, and banana bread can contain high levels of tyramine
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