A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Tell me what is concerning you."

"Your husband is making really good progress."

"Did your husband say something to upset you?"

"Crying helps us let things out and we feel better."

Answer and Explanation

The Correct Answer is A

A. "Tell me what is concerning you."

This response is the most therapeutic option. It invites the spouse to share their concerns and feelings, showing empathy and active listening. It opens the door for effective communication and understanding the spouse's perspective.

B. "Your husband is making really good progress."

While this response provides information about the husband's progress, it doesn't directly address the spouse's concerns or feelings. The spouse's emotional state needs to be acknowledged and explored before discussing the husband's progress.

C. "Did your husband say something to upset you?"

This response makes an assumption that the husband said something to upset the spouse. It might come across as accusatory or dismissive of the spouse's feelings. It's important to give the spouse the opportunity to express their emotions in their own words.

D. "Crying helps us let things out and we feel better."

This response offers a general statement about crying, but it doesn't directly address the spouse's concerns or invite further conversation. While it's true that crying can be cathartic, the focus here should be on understanding the spouse's specific worries.

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

Explanation

Fine hand tremors and pill rolling are not indicative of tardive dyskinesia. These symptoms are more commonly associated with other neurological or movement disorders.

B. Urinary retention and constipation:

Urinary retention and constipation are not symptoms of tardive dyskinesia. These symptoms are more related to anticholinergic effects of certain medications.

C. Facial grimacing and eye blinking:

Facial grimacing and repetitive, involuntary movements such as eye blinking are characteristic of tardive dyskinesia. These abnormal movements of the face and eyes are commonly seen in individuals who have been on long-term antipsychotic medications, especially older ones like haloperidol.

D. Involuntary pelvic rocking and hip thrusting movements:

Involuntary pelvic rocking and hip thrusting movements are not typical symptoms of tardive dyskinesia. These types of movements are less associated with antipsychotic-induced movement disorders.

E. Tongue thrusting and lip-smacking:

Tongue thrusting and lip-smacking are classic symptoms of tardive dyskinesia. These repetitive, involuntary movements involving the mouth and tongue are often observed in individuals who have been on antipsychotic medications for an extended period of time.

A. Schedule regular weigh-in times. B. Allow the client to eat at any time. C. Provide privacy when friends visit. D. Compliment the client for weight gain.

Correct Answer is A

Explanation

A. Schedule regular weigh-in times: Monitoring the client's weight on a regular schedule is important in managing anorexia nervosa. It helps track progress and any potential complications related to weight loss.

B. Allow the client to eat at any time: For individuals with anorexia nervosa, there is typically a structured meal plan that is carefully monitored by healthcare professionals. Allowing the client to eat at any time might disrupt the planned nutritional intake.

C. Provide privacy when friends visit: Privacy is important, but it should be balanced with ensuring the client's safety and adherence to the treatment plan. Visitors might need to be supervised to prevent any behaviors that could exacerbate the disorder.

D. Compliment the client for weight gain: While support and encouragement are important, complimenting a client for weight gain might inadvertently reinforce a focus on body image and reinforce disordered eating behavior. It's crucial to provide positive reinforcement for adherence to the treatment plan and progress in recovery, rather than emphasizing weight changes.

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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband. Which of the following is a therapeutic nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

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

Explanation

A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take?

Correct Answer is A

Explanation

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