The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

A lot of clients behave that way, but you cannot take it personally.

Have you tried to establish a therapeutic relationship with the clients?

Do you want me to assign another nurse?

Clients often behave that way when they are in pain.

Answer and Explanation

The Correct Answer is B

Choice A reason:
While this response acknowledges the nurse’s feelings, it does not provide a constructive solution or address the underlying issue. It may come across as dismissive rather than supportive.

Choice B reason:
Establishing a therapeutic relationship is fundamental to effective nursing care. This response encourages the nurse to build rapport and trust with the clients, which can improve their engagement and cooperation in their care. It is a proactive and supportive suggestion.

Choice C reason:
Offering to assign another nurse does not address the issue of building a therapeutic relationship and may not be feasible. It also does not help the nurse develop skills to improve client interactions.

Choice D reason:
While clients in pain may exhibit disinterest, this response does not address the broader issue of establishing a therapeutic relationship. It focuses on a specific cause rather than providing a general strategy for improving client engagement.

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Correct Answer is C

Explanation

Choice A reason:
Delusions of grandeur are a type of delusion where an individual believes they have exceptional abilities, wealth, or fame. This is not the correct answer because the client’s reaction of thinking others are making fun of them does not align with the belief of having grandiose qualities. Delusions of grandeur typically involve an inflated sense of self-importance, which is not evident in the scenario described.
Choice B reason:
Loose association refers to a thought disorder where ideas are presented with little or no logical connection. This is not the correct answer because the client’s reaction is more about misinterpreting the actions of others rather than displaying disorganized thinking. Loose associations would manifest as speech that is difficult to follow due to the lack of coherent connections between thoughts.
Choice C reason:
Ideas of reference involve the belief that insignificant remarks, events, or objects in one’s environment have personal meaning or significance. This is the correct answer because the client believes that the group’s laughter is directed at them, interpreting it as a personal attack. This misinterpretation of external events is a hallmark of ideas of reference, which is a common symptom in schizophrenia.
Choice D reason:
Magical thinking involves believing that one’s thoughts, words, or actions can cause or prevent specific outcomes in a way that defies the laws of cause and effect. This is not the correct answer because the client’s reaction does not involve any belief in their own ability to influence events through supernatural means. Instead, the reaction is based on a misinterpretation of the group’s behavior.

A. “Sure, give me your address, and I will see that the information is sent to you.” B. “I’ll have to get the client’s signed consent before we can send that information to you.” C. “I’m sorry, we’re not allowed to give out that information about our client.” D. “I am unable to acknowledge whether or not your employee is a client on this unit.”

Correct Answer is D

Explanation

Choice A reason:
Agreeing to send the information without the client’s consent is a breach of confidentiality. Healthcare providers must protect patient privacy and cannot disclose medical information without explicit permission from the client.
Choice B reason:
While obtaining the client’s signed consent is necessary before releasing information, this response still acknowledges that the person in question is a client, which could be a breach of confidentiality.
Choice C reason:
Stating that the information cannot be given out is correct, but it still indirectly confirms that the person is a client, which could be a breach of confidentiality.
Choice D reason:
“I am unable to acknowledge whether or not your employee is a client on this unit” is the most appropriate response. This statement protects the client’s privacy by not confirming or denying their presence in the unit, thus maintaining confidentiality.

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The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is D

Explanation

A nursing instructor is describing the impact of technology and electronic health records on psychiatric-mental health care. What would the instructor identify as a major challenge associated with technology?

A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

When applying the biopsychosocial model to a client with a mental health problem, the nurse addresses which psychological domain?

On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?