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."

Answer and Explanation

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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Correct Answer is C

Explanation

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

A. Projection B. Displacement C. Denial D. Undoing

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Correct Answer is C

Explanation

A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?

The nurse is collecting data from a client with obsessive-compulsive disorder (OCD). Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)

A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the following is an expected finding?

A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?