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?

“Mental illnesses do run in families, and I’ve had a lot of experience caring for people with mental illness.”

“Mental illness can be family related. Let’s focus the discussion on you and how you’re doing today.”

“It sounds like you are concerned that there may be a family connection to your current problem.”

“Yes, it does. I have a sister who was diagnosed several years ago with severe major depression.”

Answer and Explanation

The Correct Answer is D

Choice A reason:
This response provides general information about the hereditary nature of mental illnesses and reassures the client of the nurse’s experience. It maintains a professional boundary and does not disclose personal information, making it a therapeutic response.

Choice B reason:
This response acknowledges the client’s concern about the hereditary nature of mental illness and redirects the focus back to the client’s current situation. It is a therapeutic response that maintains professional boundaries and keeps the conversation client-centered.

Choice C reason:
This response validates the client’s concern and encourages further discussion about their feelings and experiences. It is a therapeutic response that promotes open communication and understanding.

Choice D reason:
Disclosing personal information about the nurse’s family can blur professional boundaries and shift the focus away from the client. It is considered nontherapeutic because it may make the client feel uncomfortable or distract from their own issues.

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Correct Answer is B

Explanation

Choice A reason:
Placing the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention. Seclusion should only be used when the client poses an immediate threat to themselves or others and less restrictive measures have failed. It is important to use the least restrictive interventions to manage symptoms.

Choice B reason:
Limiting the number of questions asked during assessments can help reduce the client’s anxiety and prevent overwhelming them. Clients with schizophrenia may have difficulty processing information and may become more paranoid or distressed with too many questions. This approach helps create a more supportive and manageable environment for the client.

Choice C reason:
Using frequent touch to provide client support is not recommended for clients with paranoid delusions. Physical touch may be misinterpreted as a threat or invasion of personal space, exacerbating the client’s paranoia and anxiety. It is important to respect the client’s boundaries and use other forms of support.

Choice D reason:
Directly telling the client that delusions are not real can be confrontational and may increase the client’s distress. Instead, the nurse should acknowledge the client’s feelings and provide reassurance without directly challenging their beliefs. This approach helps maintain a therapeutic relationship and supports the client’s emotional well-being.

A. Sitting at the client’s eye level B. Crossing the arms over the chest C. Sitting erect with back against the chair D. Keeping the feet flat on the floor with the legs crossed

Correct Answer is A

Explanation

Choice A reason:
Sitting at the client’s eye level conveys respect and attentiveness. It helps create a sense of equality and openness, making the client feel heard and valued. This positive body language fosters a therapeutic relationship and encourages effective communication.

Choice B reason:
Crossing the arms over the chest can be perceived as defensive or closed-off body language. It may create a barrier between the nurse and the client, hindering open communication and making the client feel unwelcome or judged.

Choice C reason:
Sitting erect with the back against the chair can convey attentiveness and professionalism, but it may also come across as rigid or formal. While it is important to maintain good posture, it is equally important to appear approachable and relaxed.

Choice D reason:
Keeping the feet flat on the floor with the legs crossed can be seen as casual or disengaged body language. It may not convey the same level of attentiveness and respect as sitting at the client’s eye level. Positive body language should make the client feel comfortable and respected.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

When communicating with a client, which would a nurse use to convey positive body language?

Correct Answer is A

Explanation

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, “My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?” Which of the following responses should the nurse make?

A nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

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?

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?