An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?
"You are probably right. Soiling the bed is a way of getting attention from the nursing staff."
"Tell me what makes you feel the client is doing this on purpose?"
"Why don't you spend more time with the client if you think that she is trying to get attention?"
"Next time this happens, tell me and I'll talk to the client about his behavior."
The Correct Answer is B
When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.
Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.
Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
The client's behavior of stating "I'm fine" despite having traumatic injuries is an example of denial, a coping mechanism that involves denying that a problem or issue exists. Projection involves attributing one's own feelings to another person, displacement involves redirecting one's emotions onto a less threatening target, and undoing involves seeking to undo or forget past actions.
Choice A, projection, would involve the client attributing their own feelings to others.
Choice B, displacement, would involve the client redirecting their emotions onto someone or something else. Finally,
choice D, undoing, would involve the client attempting to forget or undo past actions.
Correct Answer is C
Explanation
If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.
Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.
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