Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

Silence helps patients know that what they said was understood.

Patients withdraw if silences are prolonged.

Silence can provide meaningful moments for reflection.

A nurse is responsible for breaking silences.

Answer and Explanation

The Correct Answer is C

Choice A reason: While silence may sometimes convey understanding, its primary therapeutic purpose in communication is to allow the patient time to think or reflect, not simply to indicate understanding.

Choice B reason: Prolonged silence may cause withdrawal in some patients, but this is not the guiding principle in therapeutic communication. The focus should be on the value of reflection.

Choice C reason: Silence provides the patient with opportunities for reflection and processing of thoughts and emotions. It encourages deeper expression and supports therapeutic dialogue.

Choice D reason: The nurse is not always responsible for breaking silence. Sometimes allowing the patient to break the silence themselves is more therapeutic and empowering.

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Correct Answer is A

Explanation

Choice A reason: This response acknowledges the patient’s feelings without confirming or denying the delusion. It helps establish trust while maintaining therapeutic communication. By focusing on the patient’s underlying concern, it avoids reinforcing the delusional content.

Choice B reason: Stating that the CIA is prohibited in health care facilities engages with the delusion, which is non-therapeutic because it validates the false belief.

Choice C reason: Redirecting away from the delusion may seem dismissive and does not address the patient’s immediate feelings of fear or concern. This could cause the patient to feel unheard.

Choice D reason: Telling the patient they have “lost touch with reality” is confrontational and could increase defensiveness. It is not supportive or therapeutic in building rapport.

A. Restrict calories to maintain weight. B. Avoid contracting a viral infection. C. Limit iron intake. D. Abstain from getting pregnant as a teenager.

Correct Answer is B

Explanation

Choice A reason: Calorie restriction during pregnancy is not a recommended preventive measure and may actually harm fetal development by causing malnutrition.

Choice B reason: Maternal viral infections during pregnancy, such as influenza, have been associated with an increased risk of schizophrenia in offspring. Preventing infections through vaccination, hygiene, and avoiding exposure is a protective measure.

Choice C reason: Iron deficiency should be prevented, not encouraged, since adequate maternal nutrition supports healthy fetal brain development. Limiting iron intake would not reduce schizophrenia risk and could increase complications.

Choice D reason: While teenage pregnancy carries social and medical risks, it is not directly linked to increasing schizophrenia risk in offspring compared to maternal infections during pregnancy.

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Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic?

Correct Answer is A

Explanation

A nurse is teaching a client at a prenatal clinic. The client shares that they have family members diagnosed with schizophrenia and wants to know how they can reduce their baby's risk of developing schizophrenia. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A client receiving a first-generation antipsychotic develops symptoms of acute dystonia, including muscle spasms and neck stiffness. Which type of medication should the nurse anticipate administering to manage these side effects?

A nurse is caring for a client who states, "I have no interest in sexual activity or finding a partner." The nurse should identify that this statement is consistent with which of the following personality disorders?

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can’t get over my spouse’s death." Which of the following by the nurse are appropriate? (Select all that apply.)

A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply.)

A nurse working in a psychiatric unit discovers that a client has disclosed intentions to harm a specific person outside the hospital. Balancing ethical principles, what is the nurse’s most appropriate action?

A nurse practicing Peplau’s Relations Theory is working with a newly admitted client who is withdrawn and reluctant to engage. According to Peplau’s working model, which nurse action best explains the orientation phase of the nurse-client relationship?

A nurse is educating a client who has been prescribed phenelzine, an MAOI, for treatment-resistant depression. Which of the following instructions is most critical to prevent potentially life-threatening complications associated with this medication?

A client is on trial for a violent offense and the defense claims the client was legally insane at the time of the act. According to the M'Naghten Rule, which criterion must be met for the insanity defense to be valid?