A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

Identify other housing options and sources of transportation.

Notify the facility chaplain to request scheduling an appointment.

Confirm that everything will be all right because belongings can be replaced.

Maintain eye contact with the client and summarize the client's feelings.

Answer and Explanation

The Correct Answer is D

Answer is d. Maintain eye contact with the client and summarize the client’s feelings.

a. Identify other housing options and sources of transportation: While it is essential to address practical needs such as housing and transportation for clients who have experienced a crisis like a house fire, it is not the immediate priority when the client is in acute emotional distress. In this scenario, the client is expressing emotional distress and may not be ready to focus on practical solutions. Therefore, addressing the client's emotional needs should take precedence over addressing practical concerns.

b. Notify the facility chaplain to request scheduling an appointment: While spiritual support can be beneficial for individuals coping with trauma or loss, it should not be the immediate response when a client is in acute emotional distress. While the chaplain's support may be sought later as part of the client's holistic care, it should not precede addressing the client's immediate emotional needs.

c. Confirm that everything will be all right because belongings can be replaced: This option is incorrect because it offers false reassurance and dismisses the client's feelings about their loss. While it is true that belongings can be replaced, the emotional impact of losing possessions, especially in a traumatic event like a house fire, should not be trivialized. The client's feelings of distress and uncertainty are valid and should be acknowledged and addressed by the nurse.

d. Maintain eye contact with the client and summarize the client’s feelings: Correct. This action demonstrates therapeutic communication, which is crucial in providing an atmosphere of support and safety for the client. Maintaining eye contact shows empathy, support, and advocacy, indicating to the client that their feelings are being heard and validated. Summarizing the client's feelings allows the nurse to demonstrate active listening and understanding, fostering trust and rapport between the nurse and client. By prioritizing the client's emotional needs, the nurse can help the client begin to process their feelings and move towards coping and problem-solving.

In summary, the correct answer is d because maintaining eye contact with the client and summarizing their feelings demonstrates therapeutic communication, which is essential in providing support and validation for the client's emotional distress. This approach allows the nurse to establish rapport and trust with the client, facilitating further therapeutic interventions and support.

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Correct Answer is D

Explanation

Choice A rationale:

Periods of elation with unusual talkativeness. Rationale: While periods of elation with unusual talkativeness can be associated with certain mental health conditions, such as bipolar disorder, they are not specific to schizophrenia. These symptoms are more indicative of mania, which is characteristic of bipolar disorder.

Choice B rationale:

Recurrent thoughts of past trauma. Rationale: Recurrent thoughts of past trauma can be associated with various mental health disorders, including post-traumatic stress disorder (PTSD), but they are not specific to schizophrenia. Schizophrenia is primarily characterized by disturbances in thought processes, perception, and behavior.

Choice C rationale:

Preoccupied with folding clothes. Rationale: Preoccupation with folding clothes is not a hallmark symptom of schizophrenia. Schizophrenia is characterized by symptoms such as hallucinations, delusions, disorganized thinking, and impaired social functioning.

Choice D rationale:

Invents words that have no meaning. Rationale: This statement is correct. Inventing words that have no meaning, also known as "neologisms," is a symptom often observed in individuals with schizophrenia. Neologisms are a manifestation of disorganized thinking and communication.

A. "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice.” B. "Tell me more about your concerns about taking chemotherapy.” C. "Using nontraditional treatments is not a good idea. I'd rather you avoid that route.” D. "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you.”

Correct Answer is B

Explanation

The correct answer is choice B: "Tell me more about your concerns about taking chemotherapy."

Choice A rationale:

This response focuses on negative outcomes and might discourage the client from exploring her options. It does not support the client's autonomy or address her concerns about nontraditional treatments. The nurse's role should be to facilitate open communication and understanding.

Choice B rationale:

This response is the most therapeutic. By inviting the client to share her concerns, the nurse demonstrates empathy and encourages the client to express her thoughts and feelings. This approach fosters a collaborative and respectful relationship, allowing the nurse to address the client's worries effectively.

Choice C rationale:

This response is directive and dismissive of the client's wishes. It fails to consider the client's perspective and autonomy. The nurse should avoid imposing personal opinions and instead promote a patient-centered approach.

Choice D rationale:

While acknowledging the provider's expertise is important, this response does not address the client's concerns about nontraditional treatments. It's essential to focus on the client's individual preferences and provide information to help her make an informed decision.

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A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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