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 B
Explanation
A. Being married might have protective factors against depression for some individuals due to social support; however, it's not universally a risk factor.
B. Chronic illness, due to its impact on quality of life, pain, and coping mechanisms, is a well-known risk factor for developing depression.
C. While depression can affect anyone regardless of gender, it's not accurate to label male gender as a risk factor in itself.
D. Pregnancy can be associated with perinatal mood disorders like postpartum depression, but it's not a universal risk factor for depression in all cases.
Correct Answer is C
Explanation
A. Dismissing the client's statement as manipulation without proper assessment can be dangerous.
B. While involving family support is important, this response doesn’t address the immediate safety concerns of the client.
C. Asking about suicidal plans helps assess the level of risk and informs subsequent actions to ensure the client's safety.
D. The situation requires more immediate assessment and action due to the expressed suicidal ideation.
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