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. Sleep disturbances are common in PTSD, but they might not address the current acute symptoms the client is experiencing.
B. This question explores the immediate trigger for an outburst but might not directly address the PTSD symptoms related to the sexual assault.
C. Inquiring about flashbacks directly relates to one of the hallmark symptoms of PTSD, especially given the recent severe anxiety related to the assault.
D. Avoidance behavior is a symptom of PTSD, but the question about experiencing a flashback addresses more immediate distress.
Correct Answer is B
Explanation
A. Elevated levels of serotonin are associated with a potential treatment for depression but aren't considered a primary risk factor for developing depression.
B. Past history of childhood trauma, such as abuse or neglect, is a well-established risk factor for the development of depression later in life.
C. Being an only child is not recognized as a primary risk factor for depression.
D. Recent history of stressful positive life events might not be a primary risk factor for depression; in some cases, it could be a protective factor.
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