A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?

Invite a family member to be present for the nursing history.

Provide basic wound care for obvious physical injuries.

Be direct and honest when speaking with the client.

Probe the client to offer a factual account of the abuse.

Answer and Explanation

The Correct Answer is C

Rationale for A: Inviting a family member to be present may hinder communication, especially if the family member is involved in the abuse or the client feels unsafe speaking in their presence. Privacy is crucial for encouraging open communication.

Rationale for B: Providing basic wound care is important for physical injuries, but it does not directly address promoting communication. The nurse should focus on creating a safe environment for the client to talk.

Rationale for C: Being direct and honest when speaking with the client promotes trust and open communication. Clients who are suspected of being abused may be fearful or reluctant to share information, so clear, respectful communication helps create a supportive environment.

Rationale for D: Probing the client for a factual account of the abuse may make the client feel pressured or overwhelmed. The nurse should allow the client to share information at their own pace without feeling forced to disclose details.

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Correct Answer is ["C","D"]

Explanation

A. Discussing the client's suicide plan might inadvertently trigger or worsen suicidal thoughts and is not recommended.
B. Restricting visitors might hinder the client's social support system, which is essential in managing depression.
C. Reinforcing statements regarding a will to live and realistic plans for the future promotes hope and positive thinking.
D. Encouraging the client to discuss thoughts and feelings about wanting to die allows for expression and processing of emotions.
E. Limiting time allowed to play video games might be part of a broader plan, but it's not directly addressing depression and might not be as impactful as other interventions.

A. It demonstrates empathy towards the client. B. It clearly articulates what is expected of the client. C. It sets limits on the client's manipulative behavior. D. It uses reflection when talking with the client.

Correct Answer is B

Explanation

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.

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A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D"]

Explanation

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Explanation

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