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 C

Explanation

Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.

A. Put the client in a quiet room B. Teach the client deep breathing C. Remain with the client D. Encourage the client to talk about their feelings and concerns

Correct Answer is C

Explanation

Choice A reason:
Putting the client in a quiet room can help reduce external stimuli and may be beneficial in managing anxiety. However, it does not address the immediate need for support and reassurance. The presence of a nurse can provide a sense of safety and help the client feel more secure during a highly anxious state.

Choice B reason:
Teaching the client deep breathing techniques is an effective strategy for managing anxiety. However, in the immediate aftermath of a traumatic event, the client may not be able to focus on learning new techniques. Providing immediate support and reassurance is more critical at this stage.

Choice C reason:
Remaining with the client is the most appropriate immediate intervention. The nurse’s presence can provide comfort, reassurance, and a sense of safety, which are crucial in managing acute anxiety. This approach helps to stabilize the client and allows for further assessment and intervention once the client is calmer.

Choice D reason:
Encouraging the client to talk about their feelings and concerns is an important part of anxiety management, but it may not be the best immediate intervention in a severe state of anxiety. Initially, the client may need more direct support and reassurance before they are able to articulate their feelings effectively. Once the client is calmer, discussing their feelings can be beneficial.

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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 interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

Correct Answer is C

Explanation

A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

Correct Answer is C

Explanation

A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

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 education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?

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

A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Which client would a nurse determine to be the most likely candidate for involuntary commitment?

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?