A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

Verbalize disapproval of the client's substance abuse.

Maintain a nonjudgmental attitude.

Offer sympathetic support.

Avoid displaying an emotional response.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Maintain a nonjudgmental attitude.

Choice A rationale:

Verbalize disapproval of the client's substance abuse. Expressing disapproval can create a negative environment and hinder the therapeutic relationship. Judgmental attitudes can make clients feel defensive and less likely to open up about their struggles.

Choice B rationale:

Maintain a nonjudgmental attitude. Maintaining a nonjudgmental attitude is crucial in building trust and rapport with clients. It creates an environment where clients feel safe discussing their issues without fear of criticism. A nonjudgmental attitude encourages open communication and helps the nurse gather relevant information to provide appropriate care.

Choice C rationale:

Offer sympathetic support. While offering support is important, sympathy might inadvertently convey pity or enable the client's behavior. Empathy, where the nurse understands and shares the client's feelings without judgment, is more effective in building a therapeutic relationship.

Choice D rationale:

Avoid displaying an emotional response. While it's important for the nurse to maintain professionalism, avoiding any emotional response might come across as cold or detached. Expressing appropriate empathy and emotions can actually enhance the therapeutic relationship.

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Correct Answer is C

Explanation

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

A. "You are not responsible for your mother's stroke, but many people in your situation feel this way.” B. "Your mother will be fine. You shouldn't worry so much.” C. "Why do you blame yourself? You could not have prevented the stroke.” D. "So, it seems that you feel responsible for what happened to your mother.”

Correct Answer is D

Explanation

The correct answer is choiced. "So, it seems that you feel responsible for what happened to your mother.”

Choice A rationale:This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.

Choice B rationale:This response is overly reassuring and dismisses the son’s feelings of guilt. It does not address his emotional state or encourage him to express his concerns.

Choice C rationale:This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.

Choice D rationale:This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.

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A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for an older adult client diagnosed with a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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