A nurse is caring for a client who states, "I don’t belong here." Which response is most appropriate?

Were you feeling this way before this hospitalization?

You don’t think this is the right place for your care?

Suggest you discuss your concerns with the doctor in the morning

This is an inappropriate statement for you to make

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking if the client felt this way before hospitalization focuses on past feelings, which may not address the current emotional state or therapeutic needs. While it gathers history, it lacks empathy and does not encourage the client to elaborate on their current concerns, making it less therapeutic.

Choice B reason: Reflecting the client’s statement by asking if they feel the setting is wrong demonstrates active listening and empathy, key components of therapeutic communication. It encourages the client to express feelings, fostering trust and exploration of their concerns, aligning with psychiatric nursing principles, making this the correct choice.

Choice C reason: Suggesting the client discuss concerns later with a doctor dismisses their current emotional state, potentially undermining trust in the nurse-client relationship. It avoids immediate engagement and fails to address the client’s feelings, which is critical in psychiatric care, making this response non-therapeutic and incorrect.

Choice D reason: Labeling the client’s statement as inappropriate is judgmental and dismissive, hindering therapeutic communication. It may increase the client’s sense of alienation or shame, contrary to psychiatric nursing goals of building trust and validating feelings. This response is non-therapeutic and does not support the client’s emotional needs.

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Correct Answer is C

Explanation

Choice A reason: Using coercive language, like stating attendance is mandatory for progress, undermines patient autonomy and may increase resistance, especially in a manic phase where defiance is common. This non-therapeutic approach hinders trust, making it incorrect for promoting engagement.

Choice B reason: Reporting refusal to the doctor without exploring the patient’s reasons dismisses their feelings and escalates authority rather than fostering collaboration. Therapeutic engagement requires understanding the patient’s perspective, making this response non-therapeutic and incorrect.

Choice C reason: Asking about the patient’s hesitation uses open-ended questioning, a therapeutic communication technique that encourages expression of feelings and builds trust. This aligns with psychiatric nursing principles to engage patients respectfully, especially during mania, making this the correct choice.

Choice D reason: Warning about missing treatment is mildly coercive and does not explore the patient’s reasons for refusal. It fails to address underlying concerns, such as anxiety or grandiosity, which are critical in mania, making this less therapeutic than exploring hesitancy.

A. You should share this thought with your psychiatrist B. I’m concerned about your safety, so I must share this with the team C. Let’s discuss why you feel this way D. I promise I won’t tell anyone about this

Correct Answer is B

Explanation

Choice A reason: Suggesting the adolescent share with the psychiatrist avoids the nurse’s duty to report imminent threats. Ethical and legal standards require immediate action for safety, making this response inadequate, as it delays intervention in a potential crisis.

Choice B reason: Reporting a threat to harm others is a legal and ethical duty in psychiatric nursing, as it indicates imminent danger. Sharing with the team ensures safety interventions, aligning with mandatory reporting laws, making this the correct response.

Choice C reason: Discussing feelings is therapeutic but does not address the immediate safety risk of a threat. Prioritizing exploration over reporting violates ethical standards for managing dangerous behaviors, making this response incorrect in this context.

Choice D reason: Promising confidentiality in the face of a threat violates nursing ethics and legal mandates to report harm risks. This undermines patient and public safety, making it a non-therapeutic and incorrect response to a serious threat.

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A nurse is caring for a client who states, "I don’t belong here." Which response is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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