Therapeutic Communication
A client with a diagnosis of schizophrenia is admitted to the inpatient unit of the mental health center. He's shouting that the government of France is trying to assassinate him. Which response is most appropriate? a) "I don't see evidence that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." b) "I think you're wrong. France is a friendly country. The French government wouldn't try to kill you." c) "You're wrong. Nobody is trying to kill you." d) "A foreign government is trying to kill you? Please tell me more about it."
A. "I don't see evidence that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." Responses should focus on reality while acknowledging the client's feelings. It isn't therapeutic for the nurse to argue with the client or deny his belief. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the client's psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.
During a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best? a) "I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling." b) "Most new mothers feel the same way that you do. I hear that a lot from others." c) "You need to have your husband and family help you so that you can get some rest." d) "The hormonal changes your body is experiencing are causing you to feel this way."
A. "I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling." Explanation: The nurse should convey empathy and invite the client to share more about her thoughts and feelings so that the nurse can assess the mother for possible postpartum depression, which usually occurs between 2 weeks and 3 months after the baby's birth but also can occur later. Postpartum depression is a mood disorder with symptoms of tearfulness, mood swings, despondency, feelings of inadequacy, inability to cope with the baby, and guilt about performance as a mother. Postpartum depression commonly goes undetected because of poor recognition and lack of knowledge. Hormonal changes during and after childbirth may account for some of the symptoms; however, the nurse should not assume that that is the case. Stating the client's husband and family should help her is an assumption that they are not and dismisses the client's concerns. Saying most new mothers feel the same way minimizes the client's concerns and decreases the likelihood of further disclosure by the client.
A client with lymphoma tells the nurse that he's found an overseas holistic physician who can cure him with coffee enemas. What should the nurse say? a) "You should ask your physician if this is a helpful approach." b) "This treatment is questionable. It could be dangerous." c) "Unproven alternative therapy can be very dangerous." d) "It's illegal for unlicensed physicians to prescribe your care."
A. "You should ask your physician if this is a helpful approach." In this situation, the nurse should try to maintain open communication and a strong therapeutic connection with the client. Although the treatment may be unproven, questionable, dangerous, or illegal, telling the client so may make the nurse appear to be harsh and judgmental, shut down dialog, and alienate the client. By referring the client to the physician, the nurse keeps lines of communication open and gives the client an opportunity to discuss treatment options in a difficult life situation.
The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time is running out." What is the nurse's best response? a) "You're in a lot of pain. What are you feeling?" b) "Let's talk about making some good use of that time." c) "Don't give up. There could be a cure for AIDS tomorrow." d) "Life is precious and worth living."
A. "You're in a lot of pain. What are you feeling?" Explanation: The nurse recognizes the client's pain, hopelessness, and sense of loss related to his condition and the loss of his friend and encourages him to express his feelings. Giving the client permission to talk about his feelings of sadness, loss, and hopelessness and listening to him is an important nursing intervention for the dying client. Do not divert attention from the content of the client's statements or block expression of feelings. "Don't give up" is a type of pep talk that ignores the client's feelings. This statement ignores the client's needs and inhibits his expression of feelings.
One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse is most therapeutic? a) "Your behavior is disturbing to the other clients. I'll walk with you around the patio to help you release some of your energy." b) "You're behaving in an unacceptable manner, and you need to control yourself." c) "You're scaring everyone in the group. Leave the room immediately." d) "If you continue to talk like that, no one will want to be around you."
A. "Your behavior is disturbing to the other clients. I'll walk with you around the patio to help you release some of your energy." This response shows that the nurse finds the client's behavior unacceptable, yet still regards the client as worthy of help. Also, the nurse is recommending an appropriate alternative to the client's inappropriate behavior. The other options critique the client's behavior and offer no appropriate alternative.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 6 to 12 months b) 1 to 3 weeks c) 2 to 4 months d) 3 to 5 days
A. 6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? a) Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician. b) Honor the mother's request. c) Request that an anesthetist administer the epidural because the client is uncomfortable. d) Knowing the client's cultural background, suggest that the family call a meeting to make the decision.
A. Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician. A pregnant adolescent is considered to be emancipated and entitled to make her own decisions. It's the adolescent's right to decide whether she wants to have an epidural. The nurse should act as the adolescent's advocate and ask her whether she wants an epidural and then speak with the physician. The adolescent's mother and other family members can't override her decision. The nurse may not request that an anesthetist administer the epidural without the adolescent's consent.
An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? a) Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician. b) Knowing the client's cultural background, suggest that the family call a meeting to make the decision. c) Request that an anesthetist administer the epidural because the client is uncomfortable. d) Honor the mother's request.
A. Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician. Explanation: A pregnant adolescent is considered to be emancipated and entitled to make her own decisions. It's the adolescent's right to decide whether she wants to have an epidural. The nurse should act as the adolescent's advocate and ask her whether she wants an epidural and then speak with the physician. The adolescent's mother and other family members can't override her decision. The nurse may not request that an anesthetist administer the epidural without the adolescent's consent.
The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included? a) Aspirin-containing medications should not be taken for 2 weeks before surgery. b) After surgery, nasal packing will be in place for 7 to 10 days. c) The results of the surgery will be immediately obvious postoperatively. d) Normal saline nose drops will need to be administered preoperatively.
A. Aspirin-containing medications should not be taken for 2 weeks before surgery. Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline nose drops are not routinely administered preoperatively. The results of the surgery will not be obvious immediately after surgery because of edema and ecchymosis.
A nurse is caring for a 9-year-old child who is shy and fearful. The nurse asks the child a question, but the child does not answer immediately. What is the best approach by the nurse to develop a therapeutic relationship with the child? a) Remain silent after asking a question. b) Use common clichés when asking questions. c) Explain the question with medical words. d) Tell the child the consequences of not answering.
A. Remain silent after asking a question. Silence offers an opportunity for the child to answer spontaneously and cautiously. More information is usually forthcoming if the nurse gives the child the opportunity to respond. All other choices are could potentially interfere with communication in the pediatric population.
A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? a) "On the morning of surgery, I won't use lotions or cosmetics." b) "On the morning of the surgery, I can shave my surgical area at home to save time." c) "I should begin to use an antibacterial soap a few days before my surgical procedure." d) "I'll shower before coming to the hospital on the day of the surgery."
B. "On the morning of the surgery, I can shave my surgical area at home to save time." The client shouldn't shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections. Washing with an antibacterial soap for a few days before surgery reduces the skin's bacterial count. The client shouldn't use lotions or cosmetics on the day of the surgery. The client can shower before coming to the hospital.
A client tells a nurse that people from Mars are going to invade the Earth. Which response by the nurse would be therapeutic? a) "I know you believe the Earth is going to be invaded, but I don't believe that." b) "That must be frightening to you. Can you tell me how you feel about it?" c) "What do you mean when you say they're going to invade the Earth?" d) "There are no people living on Mars."
B. "That must be frightening to you. Can you tell me how you feel about it?" This response addresses the client's underlying fears without feeding the delusion. Refuting the client's delusion would increase his anxiety and reinforce his delusion. Asking the client to elaborate on his delusion would also reinforce the delusion. Voicing disbelief about the delusion wouldn't help the client deal with his underlying fears.
When administering atropine sulfate preoperatively to a client scheduled for lung surgery, the nurse should tell the client which of the following a) "This medicine will make you drowsy." b) "This medicine will make your mouth feel dry." c) "This medicine will reduce the risk of postoperative infection." d) "This medicine will help you relax."
B. "This medicine will make your mouth feel dry." Explanation: Atropine is an anticholinergic drug that decreases mucus secretions in the respiratory tract and dries the mucus membranes of the mouth, nose, pharynx, and bronchi. Atropine does not cause drowsiness or relaxation. Moderate to large doses cause tachycardia and palpitations. Large doses cause excitement and manic behavior. Atropine does not reduce the risk of postoperative infection.
Which of the following questions or statements should the nurse use to encourage client evaluation of his or her own behavior? a) "I can hear that it's still hard for you to talk about this." b) "What did you do differently with your coworker this time?" c) "What will it take to carry out your new plans?" d) "So what does this all mean to you now?"
B. "What did you do differently with your coworker this time?" Asking for descriptions of changes in behavior (what the client did differently) encourages evaluation. Conveying empathy, such as stating that it is still hard for the client to talk about it, encourages data collection. Asking for meaning helps with the nursing diagnosis. Asking the client about what her husband said the previous night is part of evaluation.
A client is entering rehabilitation for alcohol dependency as an alternative to going to jail for multiple DUI's (driving under the influence). While obtaining the client's history, the nurse asks about the amount of alcohol he consumes daily. He responds, "I just have a few drinks with the guys after work." Which of the following responses by the nurse is most therapeutic? a) "I guess you just can't handle a few drinks." b) "You say you have a few drinks, but you have multiple arrests." c) "That's what all the clients here say at first." d) "Then you should have had a designated driver for yourself."
B. "You say you have a few drinks, but you have multiple arrests." The best way to intervene with a client's minimization or denial of alcohol problems is to point out the consequences of the drinking—the multiple arrests. The other responses are superficial and discount the seriousness of the client's problem.
A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which technique? a) Reassurance b) Making observations c) Clarifying d) A broad, opening statement
B. Making observations The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn't give feedback to the client. The nurse didn't ask the client to explain his actions (the clarifying technique) and didn't reassure him.
A female client in an anger management group states, "My doctor tells me I need to get mad more often and not let people tell me what to do. Maybe she thinks I should be more aggressive." What information should the nurse incorporate in the response to this client? a) Denial of anger and lack of assertiveness can be as serious as aggressiveness. b) The client has most likely misinterpreted what the primary health care provider said. c) The client is trying to gain acceptance by the group. d) Assertive behavior in women is not culturally acceptable.
B. The client has most likely misinterpreted what the primary health care provider said. It is unlikely that the primary health care provider would imply that the client should be more aggressive. Denial of anger with passive, unassertive behavior and the aggressive expression of anger are dysfunctional behavior patterns. Gender-based stereotypes are not conducive to mental health, and deeming assertive behavior in women as culturally unacceptable interferes with the goal of developing assertiveness skills. Group acceptance should not be based on whether a client is demonstrating assertive or aggressive behavior.
A client with alcohol dependence states, "I feel so bad because of what I've done to my wife and kids. I'm just no good." Which of the following responses by the nurse is most appropriate? a) "You'll need to make up for a lot of things." b) "Alcoholism is painful for everyone involved." c) "Alcohol dependence is a disease that can be treated." d) "They will need to forgive your shortcomings."
C. "Alcohol dependence is a disease that can be treated." Explanation: The most appropriate response is, "Alcohol dependence is a disease that can be treated" because it conveys hope. It also emphasizes that the client has a treatable illness, which is helpful in reducing denial and guilt and encouraging the client to seek and comply with treatment. The other statements are judgmental and guilt-producing, possibly leading to denial and furthering the need for alcohol.
While coaching a youth soccer team, the nurse has observed one of the teammates bingeing and purging on multiple occasions. The nurse asks the girl's mother to stay after practice and talk privately. Which of the following ways is best for the nurse to begin the conversation? a) "Let me get right to the point. Your daughter is very sick and needs to see a mental health therapist right away." b) "I have some very bad news for you. Your daughter has a serious problem that is diagnosed as an eating disorder." c) "I am a nurse. I have seen your daughter doing things that are considered to be part of an eating disorder." d) "Thank you for letting your daughter play on the team. She's a very good player and is also pleasant and easy to coach."
C. "I am a nurse. I have seen your daughter doing things that are considered to be part of an eating disorder." By telling the mother that the coach is a nurse and relaying the behaviors observed, the nurse gives the mother a chance to recognize the expertise of the coach and introduces the possibility of an eating disorder. Thanking the mother and complimenting the player does not begin to approach the topic. Telling the mother that the nurse has some very bad news is negative and dramatic. Additionally, although the observed behaviors suggest an eating disorder, it would be inappropriate for the nurse to medically diagnose the daughter. Although the daughter may indeed be very sick and need to see a therapist, the nurse should relate the information in a matter-of-fact, unemotional way.
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate? a) "You really shouldn't leave right now. Your child is very sick." b) "Can you find someone to stay with your children? Your child needs you here." c) "I understand, but feel free to visit or call anytime to see how your child is doing." d) "It really isn't necessary to stay with your child. We'll take very good care of him."
C. "I understand, but feel free to visit or call anytime to see how your child is doing." The nurse's best course of action would be to support the mother. This is best done by conveying understanding and encouraging the mother to visit or call. Telling the mother that she shouldn't leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to find someone else to stay with her children is inappropriate. The children at home also need the support of the mother and/or other family members to minimize the disruptions in family life resulting from the toddler's hospitalization and to maintain consistency
The parents of a child tell the nurse that they feel guilty because their child almost drowned. Which of the following remarks by the nurse would be most appropriate? a) "You really shouldn't feel guilty; you're lucky because your child will be all right." b) "I can understand why you feel guilty, but these things happen." c) "Tell me a little bit more about your feelings of guilt." d) "You should not have taken your eyes off of your child."
C. "Tell me a little bit more about your feelings of guilt." Explanation: Guilt is a common parental response. The parents need to be allowed to express their feelings openly in a nonthreatening, nonjudgmental atmosphere. Telling the parents that these things happen does not allow them to verbalize their feelings. Telling the parents that they should not have taken their eyes off the child blames them, possibly further contributing to their guilt. Telling the parents that they shouldn't feel guilty denies the parents' feelings of guilt and is inappropriate. Telling the parents that they are lucky that the child will be okay does not remove the feelings of guilt.
After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs. He calls the nurse in excitement to report the leg movement. Which of the following responses by the nurse would be the most accurate? a) "This is a good sign. Keep trying to move all the affected muscles." b) "These movements indicate that the damaged nerves are healing." c) "The movements occur from muscle reflexes that can't be initiated or controlled by the brain." d) "The return of movement means that eventually you should be able to walk again."
C. "The movements occur from muscle reflexes that can't be initiated or controlled by the brain." The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control.
As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They'll see you!" Which of the following responses by the nurse would be best? a) "What will happen if they do see me?" b) "No one will see me." c) "Who are 'they'?" d) "You have no reason to be afraid."
C. "Who are 'they'?" Asking the client who "they" are when he is fearful helps the nurse understand his behavior and is least demanding of the client. The client is unlikely to accept statements that indicate that no one will see the nurse. The client is unlikely to accept statements that there is no reason to be afraid. Asking the client what will happen if someone sees the nurse is also unlikely to be acceptable and validates the client's delusion.
Prior to surgery for a modified radical mastectomy, the client is extremely anxious and asks many questions. Which of the following approaches would offer the best guide for the nurse to answer questions raised by this apprehensive preoperative client? a) Delay discussing the client's questions with her until her apprehension subsides. b) Delay discussing the client's questions with her until she is convalescing. c) Tell the client as much as she wants to know and is able to understand. d) Explain to the client that she should discuss her questions first with the physician.
C. Tell the client as much as she wants to know and is able to understand. An important nursing responsibility is preoperative teaching, and the most frequently recommended guide for teaching is to tell the client as much as she wants to know and is able to understand. Delaying discussion of issues about which the client has concerns is likely to aggravate the situation and cause the client to feel distrust. As a general guide, the client would not ask the question if she were not ready to discuss her situation. The nurse is available to answer the client's questions and concerns and should not delay discussing these with the client.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that: a) Alcoholism is a major health problem, and all clients are questioned about alcohol intake. b) Alcohol intake can interfere with the tests used to diagnose pancreatitis. c) There is a strong link between alcohol use and acute pancreatitis. d) The physician must obtain the pertinent facts, regardless of religious beliefs.
C. There is a strong link between alcohol use and acute pancreatitis. Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. Physicians do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.
A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. "I don't know why she didn't keep the doors locked like I told her. I can't believe she has had sex with another man now." The nurse should respond by saying: a) "Maybe the doors were locked, but the man broke in anyway." b) "It was not consensual sex. Let's see if your wife was physically injured." c) "Your wife needs your support right now, not your criticism." d) "Let's talk about how you feel. Maybe it would help to talk to other men who have been through this."
D. "Let's talk about how you feel. Maybe it would help to talk to other men who have been through this." Explanation: The nurse should respond to the husband's needs and concerns and should offer support. Protecting or defending the wife against his criticism ignores the husband's needs.
The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." The nurse should respond: a) "Don't worry, we'll protect you. No one can come here to harm you." b) "Why do you think someone wants to kill you?" c) "No one wants to kill you. We like you." d) "You're frightened. This is a hospital and these people are staff members. You're safe here."
D. "You're frightened. This is a hospital and these people are staff members. You're safe here." The nurse does not argue with the client having delusions. The nurse addresses the client's underlying feeling and presents reality to promote the client's trust, comfort, and sense of reality. The other statements challenge the client and further distances the client from reality, defend the staff and does not address the client's feeling, and validate the client's delusion but do not address the client's feeling and may further confuse the client.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 1 to 3 weeks b) 2 to 4 months c) 3 to 5 days d) 6 to 12 months
D. 6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: a) While taking a deep breath and holding it. b) After exhaling but before inhaling. c) While inhaling through an open mouth. d) While exhaling through pursed lips.
D. While exhaling through pursed lips. Explanation: Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.
A nurse is assessing a client at a mental health clinic who threatens suicide and describes having a plan. Which of the following should the nurse recognize as the priority goal for the client? a) Obtaining admission to an acute care facility b) Establishing a foundation for long-term therapy c) Notifying family members of the suicide plan d) Working with the client to resolve the immediate crisis
D. Working with the client to resolve the immediate crisis Explanation: The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his/her own problems. Although some clients do enter long-term therapy or are admitted to an acute care facility, these are not the goals of crisis intervention.