The client expresses the loneliness she feels to the nurse. Which response by the nurse demonstrates the existence of a therapeutic relationship?

Have you thought about ways to locate other lonely people?

You need to get involved in community activities.

Loneliness can be a painful and difficult emotion.

Let’s see if we have any common interests.

Answer and Explanation

The Correct Answer is C

Option c demonstrates empathy and understanding toward the client's feelings, which is an essential component of a therapeutic relationship. It acknowledges the client's emotions, validates their experience, and provides support to the client. In contrast, options a and d suggest a solution or an activity to the client, which may not be what the client needs now.

Option b is directive and may make the client feel judged or inadequate.

Therefore, option c is the best response that demonstrates the existence of a therapeutic relationship between the client and the nurse.

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Correct Answer is C

Explanation

This statement indicates a lack of understanding about the legal basis for involuntary admission and the criteria for discharge. Involuntary admission is authorized when a person is a danger to themselves or others or is gravely disabled, and the decision to discharge must be based on an evaluation by a qualified professional that the person no longer meets those criteria. Therefore, the client cannot simply leave by telling staﬀ they will not harm themselves. The other options are not indicative of a lack of understanding of the client’s rights.

Option A may indicate a concern about privacy, but the confidentiality of mental health information is protected by law, so the client's boss cannot be informed without their consent.

Option B shows an understanding of the reason for the use of restraints.

Option Ddemonstrates awareness of the right to vote, which is not aﬀected by mental health status.

A. Disassociation-adaptive B. Denial-adaptive C. Rationalization-maladaptive D. Altruism-maladaptive

Correct Answer is A

Explanation

Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide eﬀective care and support to the family despite the chaotic environment.

Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selﬂessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.

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The client expresses the loneliness she feels to the nurse. Which response by the nurse demonstrates the existence of a therapeutic relationship?

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Naxlex Comprehensive Predictor Exams

A client was involuntarily admitted to a behavioral health facility after trying to harm himself. Which statement by the client would indicate further education is needed regarding his rights?

Correct Answer is C

Explanation

A nurse is speaking to the family of a Trauma victim. The nurse is blocking out the siren and alarm noises while speaking with the client’s family. They ask,” How can you be so calm and focused with all this noise going on?” The nurse is practicing which defense mechanism?

Correct Answer is A

Explanation

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