Mental Health

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? 1.The client's report of not eating or sleeping 2.The presence of bruises on the client's body 3.The client's report of self-destructive thoughts 4.The family member is disapproving of the treatment.

3. The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply? 1."In 7 days" 2."In 14 days" 3."In 21 days" 4."Within a few hours"

4. Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client? 1."I don't see you as a failure." 2."You have everything to live for." 3."Feeling like this is all part of being ill." 4."You've been feeling like a failure for a while?"

4. Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct response is an example of the use of restating. The incorrect responses block communication because they minimize the client's feelings and do not facilitate exploration of his or her expressed feelings.

The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply. 1.Mutual learning 2.Increased feedback 3.Instilling a sense of belonging 4.Acutely manic clients can attend 5.Opportunity to practice individual roles 6.An opportunity to practice new skills in a relatively safe environment

1.,2.,3.,6. Besides cost savings, advantages that a group format has over individual therapy include increased feedback, an opportunity to practice new skills in a relatively safe environment, mutual learning, and instilling a sense of belonging. Acutely manic clients should not attend these groups. Also, there is an opportunity to practice group roles and not individual ones.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? 1.Dilated pupils, tachycardia, and diaphoresis 2.Yawning, irritability, diaphoresis, cramps, and diarrhea 3.Tachycardia, hypertension, sweating, and marked tremors 4.Depressed feelings, high drug craving, fatigue, and agitation

2. Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids. Option 1 describes intoxication from hallucinogens. Option 3 describes withdrawal from alcohol. Option 4 describes withdrawal from cocaine.

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? 1.Plan short-term goals. 2.Identify expected outcomes. 3.Assist with making appropriate referrals. 4.Assist with developing realistic solutions

3. Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.

Which client is most likely at risk to become a victim of elder abuse? 1.A 75-year-old man with moderate hypertension 2.A 68-year-old man with newly diagnosed cataracts 3.A 90-year-old woman with advanced Alzheimer's disease 4.A 70-year-old woman with early diagnosed Lyme disease

3. Elder abuse is widespread and occurs among all subgroups of the population. It includes physical and psychological abuse, the misuse of property, and the violation of rights. The person at highest risk of abuse is an elder with dementia that occurs with Alzheimer's disease.

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1.Call the client's family. 2.Place the client in seclusion immediately. 3.Inform the client that seclusion has not been prescribed. 4.Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

4. A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only with the written prescription of the PHCP, which must be reviewed and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used.

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply. 1.Looks at old snapshots of family 2.Constantly neglects personal grooming 3.Visits the spouse's grave once a month 4.Visits the senior citizens' center once a month 5.Prefers to spend time alone and avoids contact with others

1, 3, & 4 Coping mechanisms are behaviors that are used to decrease stress and anxiety. Visiting a spouse's grave, visiting the senior citizens' center, and looking at snapshots of the family are effective coping mechanisms. Neglecting grooming and preferring to spend time alone and avoiding contact with others are behaviors that identify ineffective coping of the grieving process.

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention? 1.Escort the manic client to his or her room. 2.Orient the client to time, person, and place. 3.Tell the client that the behavior is not appropriate. 4.Tell the client that smoking privileges are revoked for 24 hours.

1. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate has already been attempted by the psychiatric nurse's aide.

In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? 1.Plan nothing until the client asks to participate in the milieu. 2.Encourage the client to participate in a structured daily program of activities. 3.Give the client a menu of daily activities and insist that the client participate in all activities offered. 4.Provide an activity that is quiet and solitary in nature to avoid increased fatigue, such as drawing or reading a book.

2. A depressed person suffers with depressed mood and is often withdrawn. Also, the person experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment rather than a quiet and solitary one.

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event? 1.Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client

2. A situational crisis is associated with a life event. External situations that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? 1.Move the client next to the nurse's station. 2.Use a night light and turn off the television. 3.Keep the television and a soft light on during the night. 4.Play soft music during the night and maintain a well-lit room.

2. It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement? 1."The technician is not going to hurt you but is going to help." 2."Are you fearful and think that others may want to hurt you?" 3."What makes you think that the technician wants to hurt you?" 4."The technician will leave and come back later for your blood."

2. Option 2 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options 1, 3, and 4 do not focus on the client's feelings.

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? 1.Administer an antianxiety agent. 2.Examine and treat the wound sites. 3.Secure and record a detailed history. 4.Encourage and assist the client with venting their feelings.

2. The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? 1.Engaging in immoral acts 2.Always reinforcing self-approval 3.Observing rigid rules and regulations 4.Having the need to always make the right decision

3. Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options 1, 2, and 4 are incorrect.

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? 1."With whom do you live?" 2."Who is available to help you?" 3."What leads you to seek help now?" 4."What do you usually do to feel better?"

3. The nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 will assist with determining data related to the precipitating event that led to the crisis. Options 1 and 2 identify situational supports. Option 4 identifies personal coping skills.

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts? 1.The false belief that one is a very powerful person 2.The false belief that one is a very important person 3.The false belief that one's partner is being unfaithful 4.The false belief that one is being singled out for harm by others

4. A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is being unfaithful.

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group? 1.Al-Anon 2.Fresh Start 3.Families Anonymous 4.Alcoholics Anonymous

4. Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for parents of children who abuse substances.

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care? 1.Facing the client when providing care 2.Ensuring that a security officer is within the immediate area 3.Keeping the door to the client's room open when with the client 4.Assigning the client to a room at the end of the hall to prevent disturbing the other clients

4. The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client's room should be kept open, and the nurse should never turn away from the client. A security officer or male aide should be within immediate call in case the possibility of violence is suspected.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? 1.Poor dietary choices 2.Lack of exercise and poor diet 3.Inadequate dietary intake and dehydration 4.Psychomotor retardation and side effects of medication

4. (I don't like this answer lol) In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1.A fear of leaving the house 2.A fear of riding in elevators 3.A fear of speaking in public 4.A fear of uncleanliness and the need to bathe every hour

1. Agoraphobia is a fear of open spaces (i.e., leaving the house); panic attacks may occur when doing so. Option 2 describes a fear of closed spaces (claustrophobia). Option 3 describes a fear of public speaking (social phobia). Option 4 describes an obsessive-compulsive behavior.

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention? 1.Feed, bathe, and dress the client as needed until the client can perform these activities independently. 2.Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. 3.Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living. 4.Have the client's peers confront the client about how their noncompliance with addressing activities of daily living affects the milieu.

1. The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options 2 and 3 are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option 4 will increase the client's feelings of poor self-esteem and unworthiness.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply. 1.Restating 2.Listening 3.Asking the client, "Why?" 4.Maintaining neutral responses 5.Giving advice, approval, or disapproval 6.Providing acknowledgment and feedback

1.,2.,4.,6. Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note? 1.The client will be angry and will refuse care. 2.The client will participate in the treatment plan. 3.The client will be very resistant to treatment measures. 4.The client's family will be very resistant to treatment measures.

2. Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1 and 3 are not likely for a client seeking voluntary admission. Option 4 is not centered on the individual client.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? 1.A client with pneumonia 2.A client receiving diagnostic tests 3.A client who thrives on managing others 4.A client who could benefit from the client's assistance at mealtimes

2. The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? 1."My medications won't make me anxious." 2."I'll go to a support group and talk so that I won't hurt anyone." 3."I won't get anxious or hear things if I get enough sleep and eat well." 4."I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

4. There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note? 1.The client presents a harm to self. 2.The client requested the admission. 3.The client consented to the admission. 4.The client provided written application to the facility for admission.

1. Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options 2, 3, and 4 describe the process of voluntary admission.

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply. 1.Promoting self-care and independence 2.Acting as an intermediary between the client and family 3.Accompanying the client to all group therapy sessions 4.Facilitating communication of distressing thoughts and feelings 5.Helping clients examine self-defeating behaviors and test alternatives 6.Assisting clients with problem solving to help facilitate activities of daily living

1.,4.,5.,6. A therapeutic nurse-client relationship may be loosely defined, but specific goals and functions must include facilitating communication of distressing thoughts and feelings, assisting clients with problem solving to help facilitate activities of daily living, helping clients examine self-defeating behaviors and test alternatives, and promoting self-care and independence. Acting as an intermediary between the client and family and accompanying the client to all group therapy sessions are not necessary or reasonable goals and functions in the nurse-client relationship.

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? 1.Interrupt the client and weigh her immediately. 2.Interrupt the client and offer to take her for a walk. 3.Allow the client to complete her exercise program. 4.Tell the client that she is not allowed to exercise vigorously.

2. Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on vigorous activities. Options 1, 3, and 4 are inappropriate nursing actions.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? 1.The mother should restrict the daughter's socializing time with her friends. 2.The mother should restrict the amount of chocolate and caffeine products in the home. 3.The mother should keep her daughter out of school until she can adjust to the school environment. 4.The mother should consider taking time off of work to help her daughter readjust to the home environment.

2. Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options 1 and 3 are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work.

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse? 1."Why did you get started on these drugs?" 2."How much do you use and what effect does it have on you?" 3."How long did you think you could take these drugs without someone finding out?" 4.The nurse does not ask any questions because of fear that the client is in denial and will throw the nurse out of the room.

2. Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? 1.Request that a peer remain with the client at all times. 2.Remove the client's clothing and place the client in a hospital gown. 3.Assign a staff member to the client who will remain with him or her at all times. 4.Admit the client to a seclusion room where all potentially dangerous articles are removed.

3. Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one-on-one) with a staff member who is never less than an arm's length away is the safest intervention.

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? 1."I know you feel 'they are out to get you,' but it's not true." 2."I can hear the voice, and she wants you to come to dinner." 3."Sometimes people hear things or voices others can't hear." 4."I talked to the voices you're hearing and they won't hurt you now."

3. It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding? 1.Normal 2.Regressive 3.Indicative of the client's ambivalence 4.Evidence of the client's altered and distorted body image

4. Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of distorted body image. The client's behavior is not normal.

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1.Provide safety for the client and other clients on the unit. 2.Provide the clients on the unit with a sense of comfort and safety. 3.Assist the staff with caring for the client in a controlled environment. 4.Offer the client a less-stimulating area to calm down and gain control.

1. Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client centered. Option 4 addresses the client's needs.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior? 1.The client is at increased risk for suicide. 2.The client is dealing with pertinent issues. 3.The client may need some time off the unit. 4.The client is responding normally to hospitalization.

1. The behaviors identified in the question may be manifested by the client who is contemplating suicide. In clients who are depressed, anger may be self-directed in the form of suicide. Many of these symptoms are those of the depressed client; however, with this client, these behaviors have increased. Hospitalization may actually lessen these symptoms in the depressed client because a feeling of hope or relief may occur once treatment begins. Dealing with pertinent issues may be traumatic, but this is not the best interpretation of the behavior. Time off the unit for this client could put the client at risk for injury.

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? 1.A puzzle 2.Drawing 3.Checkers 4.Paint by number

2. Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? 1."You need to stop that behavior now!" 2."You will need to be placed in seclusion!" 3."What is causing you to become agitated?" 4."You will need to be restrained if you do not change your behavior."

3. The best statement is to ask the client what is causing the agitation. This will assist the client with becoming aware of the behavior and will assist the nurse with planning appropriate interventions for the client. Option 1 is demanding behavior, which could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms? 1.Hypotension, ataxia, vomiting 2.Stupor, agitation, muscular rigidity 3.Hypotension, bradycardia, agitation 4.Hypertension, disorientation, hallucinations

4. The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? 1."No, I won't tell anyone." 2."I cannot promise to keep a secret." 3."If you tell me the secret, I will tell it to your doctor." 4."If you tell me the secret, I will need to document it in your record."

2. The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention? 1.Ask direct questions to encourage talking. 2.Leave the client alone and intermittently check on them. 3.Sit beside the client in silence and verbalize occasional open-ended questions. 4.Take the client into the dayroom with other clients so they can help watch him.

3. Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur. Option 4 relies on other clients to care for this one, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 is the best action because it provides for client supervision and communication as appropriate.

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills? 1."I will be more careful to make sure that my father's needs are met." 2."Now that my father is moving into my home, I will need to change my ways." 3."I feel better able to care for my father now that I know where to obtain assistance." 4."I am so sorry and embarrassed that the abusive event occurred. It won't happen again."

3. Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance with caring for aging family members can bring much-needed relief. Taking advantage of these alternatives is a positive alternative coping strategy, which many families use.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? 1.Open-ended questions and silence 2.Focusing on self-disclosure regarding food preferences 3.Stating the reasons that the client may not want to eat 4.Offering opinions about the necessity of adequate nutrition

1. Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option 2 is not a client-centered intervention.

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates a need for further teaching about this self-help group? 1."The leader of this self-help group is the nurse or psychiatrist." 2."The members of this self-help group provide support to each other." 3."This self-help group is designed to serve people who have a common problem." 4."In this self-help group, people who have a similar problem are able to help others."

1. There is a need for further teaching when the client with an eating disorder at an Overeaters Anonymous group meeting states that the leader of this self-help group is the nurse or psychiatrist. The leader of a self-help group is an experienced member of the group. The nurse or psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group. The remaining statements contain characteristics of a self-help group.

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? 1.A crisis state indicates that the individual is suffering from a mental illness. 2.A crisis state indicates that the individual is suffering from an emotional illness. 3.Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. 4.A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

4. Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness.

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response? 1."It sounds as though you need to speak to the psychiatrist." 2."Perhaps you'd like to see the ECT room and speak to the staff." 3."Your child has decided to have this treatment. You should be supportive of the decision." 4."It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

4. The nurse needs to encourage the family and client to verbalize their fears and concerns. Option 4 is the only option that encourages verbalization. Options 1, 2, and 3 avoid dealing with the client or family concerns.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? 1.The client gives away a DVD and a cherished autographed picture of the performer. 2.The client runs out of the therapy group swearing at the group leader and then runs to their room. 3.The client gets angry with her roommate when the roommate borrows their clothes without asking. 4.The client becomes angry while speaking on their cell phone and slams the phone down on her bed.

1. A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered. Options 2, 3, and 4 identify acting-out behaviors.

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse? 1.Agoraphobia 2.Hematophobia 3.Claustrophobia 4.Hypochondriasis

1. Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with somatic symptom disorder focus their anxiety on physical complaints and are preoccupied with their health.

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement? 1."I no longer feel that I deserve the beatings my husband inflicts on me." 2."My attendance at the meetings has helped me to see that I provoke my husband's violence." 3."I enjoy attending the meetings because they get me out of the house and away from my husband." 4."I can tolerate my husband's destructive behaviors now that I know they are common for alcoholics."

1. Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option 1 is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control (option 2). Option 3 indicates that the group is being seen as an escape, not a place to work on issues. Option 4 indicates that the wife remains codependent.

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? 1.Denial 2.Projection 3.Regression 4.Rationalization

1. Denial is the refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying the unacceptable attributes about oneself.

The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1.One-to-one suicide precautions 2.Suicide precautions, with 30-minute checks 3.Checking the whereabouts of the client every 15 minutes 4.Asking that the client to report suicidal thoughts immediately

1. One-to-one suicide precautions are required for the client who has attempted suicide. Options 2 and 3 are not appropriate, considering the situation. Option 4 may be an appropriate nursing intervention, but the priority is stated in option 1. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself.

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder? 1.Monitor intake and output. 2.Monitor electrolyte levels. 3.Observe for excessive exercise. 4.Monitor for the use of laxatives and diuretics.

3. Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for both dehydration and electrolyte imbalance is an important nursing action. Option 3 is the only option that is not associated with care of the client with bulimia.

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder? 1.Dental erosion 2.Electrolyte imbalances 3.Enlarged parotid glands 4.Body weight well below ideal range

4. Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. During further inspection, the client demonstrates enlargement of the parotid glands with dental erosion and caries if he or she has been inducing vomiting. Electrolyte imbalances are present.

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement? 1."Why don't you tell your husband about this?" 2."This is not the best time to make that decision." 3."What do you find difficult about this situation?" 4."I agree with you. You should get out of this situation."

3. The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply. 1.Monitor vital signs. 2.Maintain an NPO status. 3.Provide a safe environment. 4.Address hallucinations therapeutically. 5.Provide stimulation in the environment. 6.Provide reality orientation as appropriate.

1.,3.,4.,6. When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake must be maintained.

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? 1.Watch the behavior escalate before intervening. 2.Attempt to talk with the client to de-escalate the behavior. 3.Offer to take the client to an examination room until he or she can be treated. 4.Inform the client that he or she will be asked to leave if the behavior continues.

3. Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? 1.Identifying the client's ability to function 2.Identifying the client's potential for self-harm 3.Inquiring about the client's feelings that may affect coping 4.Inquiring about the client's perception of the cause of the neighbor's death

3. The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? 1."Have you talked to your family about this?" 2."Everyone feels this way when they are depressed." 3."You will feel better once your medication begins to work." 4."You sound very upset. Are you thinking of hurting yourself?"

4. Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Options 1, 2, and 3 are not therapeutic responses.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? 1.Weight loss 2.Sleep pattern 3.Medication compliance 4.Onset of the crying spells

1. All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action? 1.Call the nursing supervisor. 2.Call security to block all exit areas. 3.Tell the client that she cannot return to this hospital again if she leaves now. 4.Restrain the client until the primary health care provider (PHCP) can be reached.

1. The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Notifying the nurse supervisor is the correct option. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the PHCP before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care (option 3) and cannot be told otherwise.

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? 1."I cannot discuss any client situation with you." 2."I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" 3."You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." 4."I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"

1. The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option 3 is correct in a sense, but it is a rather blunt statement. Both options 2 and 4 identify statements that do not maintain client confidentiality.

The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching? 1."I am the nurse and, as such, I'll have you know that all information is kept confidential." 2."I realize this is hard for you to speak about, but anything you tell me will be kept strictly confidential." 3."I know that some of these questions are difficult for you, but as the nurse, I must legally respect your confidentiality." 4."I understand you must hate being asked these sorts of questions, but I promise anything you tell me will be kept private."

1. There is a need for further teaching when the student nurse responds to the client about obtaining personal sexual reproductive data that "I am the nurse and, as such, I'll have you know that all information is kept confidential". The nursing student is acting pompously, and the response is not therapeutic. The other responses are therapeutic and acknowledge the client's discomfort with the questions and assure the confidentiality of the client's response.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client. 2.Follow through about the consequences of behavior in a nonpunitive manner. 3.Ensure that the client knows that he or she is not in charge of the nursing unit. 4.Assist the client with developing a means of setting limits on personal behavior. 5.Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6.Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

1.,2.,4.,6. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client with developing a means for setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups are violations of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1.Call the client's family. 2.Persuade the client to stay a few more days. 3.Contact the primary health care provider (PHCP). 4.Tell the client that discharge is not possible at this time.

3. Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the PHCP. Option 1 violates client confidentiality. Option 2 is not therapeutic or appropriate. Option 4 does not apply to a voluntary admission status.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? 1."Have you shared your feelings with your family?" 2."I think we should talk more about your anger with your family." 3."You're feeling angry that your family continues to hope for you to be 'cured'?" 4."Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

3. Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option 1, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? 1.Psychosis 2.Repression 3.Conversion disorder 4.Dissociative disorder

3. A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply. 1.Autocratic leader 2.Democratic leader 3.Independent leader 4.Conservative leader 5.Laissez-faire leader 6.Problem-solving leader

1.,2.,5. There are three main styles of group leadership, and a leader selects the style that is best suited to the therapeutic needs of a particular group. The autocratic leader exerts control over the group and does not encourage much interaction among members. In contrast, the democratic leader supports extensive group interaction in the process of problem solving. Psychotherapy groups most often employ this empowering leadership style. A laissez-faire leader allows the group members to behave in any way they choose and does not attempt to control the direction of the group. In any group, the leader must be thoughtful about communication techniques since these can have a tremendous impact on group content and process.

An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply. 1.Is it in the best interest of society? 2.Is it covered by the client's insurance? 3.Does its use violate the client's rights? 4.Is this therapy in the best interest of the client? 5.How many days before positive results are seen? 6.Has the client's family given permission for this therapy?

1.,3.,4. Aversion therapy, also known as aversion conditioning or negative reinforcement, is a technique used to change behavior. In this therapy, a stimulus attractive to the client is paired with an unpleasant event in hopes of associating the stimulus with negative properties. Before beginning this therapy, the following questions must be answered by the therapist, treatment team, or society: (1) Is the therapy in the best interest of society? (2) Does it violate the client's rights? (3) Is it in the best interest of the client? The following questions are not related to beginning this therapy: (1) Is it covered by the client's insurance? (2) How long will it take for positive results? (3) Has the client's family given permission for this therapy? If aversion therapy is chosen as the most appropriate treatment, ongoing supervision, support, and evaluation of those administering it must occur.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take? 1.Tell the client that this is not true and that we all have a purpose in life. 2.Remain with the client and sit in silence until the client verbalizes feelings. 3.Identify recent behaviors or accomplishments that demonstrate skill or ability. 4.Reassure the client that you know how the client is feeling and that things will get better.

3. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care is to provide successful experiences for the client that are challenging but will not be met with failure to enhance the client's personal self-esteem. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of himself or herself. Options 1 and 4 offer false reassurances. Option 2 is not a therapeutic intervention with a depressed client.

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse? 1."When children are hurt the way you hurt them, people want you isolated." 2."You're lucky it doesn't escalate into something pretty scary after your crime." 3."You understand that people fear for their children, but you're feeling unfairly treated?" 4."You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened."

3. Focusing and verbalizing the implied concern is the therapeutic response because it assists the client to clarify thinking and to reexamine what the client is really saying. Option 3 is the only option that reflects the use of this therapeutic communication technique. Option 1 is insensitive and anxiety-provoking. Option 2 gives advice and does not facilitate the client's expression of feelings. Option 4 does not facilitate the client's expression of feelings.

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition should be the initial choice? 1.Weigh the client three times per week, before breakfast. 2.Explain to the client the importance of a good nutritional intake. 3.Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible. 4.Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

4. Change in appetite is one of the major symptoms of depression. Offering the client several small, frequent meals and the nurse's presence at that time to support, encourage, or perhaps even feed the client is the most appropriate intervention. A client with depression experiences poor concentration and will not understand the importance of an adequate nutritional intake. Weighing the client does not address how to increase nutritional intake. Reporting the nutritional problems to the psychiatrist is correct to some degree, but it does not address how one might increase food intake.

The nurse is assisting in conducting a group therapy session and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which? 1.Ask the client to leave. 2.Refer the client to another group. 3.Tell the client to stop monopolizing the group. 4.Suggest that the client stop talking and try listening to others.

4. If a client is monopolizing the group, it is important that the nurse be direct and decisive. The appropriate nursing action is to suggest that the client stop talking and try listening to others. Although telling the client not to monopolize the group may be a direct response, suggesting that the client stop talking and attempt to listen is the most therapeutic direct statement. The remaining options are inappropriate.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior? 1.The client needs to be admitted to the hospital. 2.The client needs to be referred to the psychiatrist as soon as possible. 3.The client requires further treatment and is not ready to be discharged. 4.The client is displaying typical behaviors that can occur during termination.

4. In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include return of signs/symptoms of anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? 1."Right! Why not just 'pack it in'?" 2."That seems rather unlikely to me." 3."I don't believe that, and neither do you." 4."You must be feeling all alone at this point."

4. The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option 1, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response. In option 2, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option 3, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions.