1. A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there
before she died." Which of the
... [Show More] following statements should the nurse make?
A. "We will call your family in time for them to get here."
Rationale: The nurse dismisses the client’s concerns and gives false reassurance.
B. "I wonder if you are fearful of dying alone."
Rationale: The nurse dismisses the client’s concerns and gives false reassurance.
C. "I will make sure a staff member is in your room at all times."
Rationale: The nurse dismisses the client’s concerns and gives false reassurance.
D. "I will tell your family of your concern so that they can be here."
Rationale: The nurse dismisses the client’s concerns and gives false reassurance.
2. A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to
concentrate. Which of the following responses should the nurse make?
A. "It sounds like you're having a difficult time."
Rationale: This therapeutic response is an open-ended, empathetic statement that encourages the client to
talk.
B. "Have you talked to your parents about this yet?"
Rationale: This nontherapeutic response is focused inappropriately on the client's parents. It does not
address the client's need to communicate or express feelings.
C. "Why do you think you are so anxious?"
Rationale: This nontherapeutic response can make the client feel defensive, and he might not be able to
tell the nurse why.
D. "How long has this been going on?"
Rationale: This nontherapeutic response is a closed-ended statement that does not encourage the client to
talk.
3. A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of
the following room assignments for the client?
A. A private room in a quiet location on the unit
Rationale: A private room in a quiet location is ideal for a client with mania. The client may easily become
overstimulated by the number of people and activities in a nursing care unit. A private room can
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Detailed Answer Key
Mental Health Progression Practice
be used for time-out during the day and to settle down to sleep at night.
B. A semi-private room with a roommate who has a similar diagnosis
Rationale: The client should not be given a semi-private room with a roommate who is also experiencing
mania because the situation would be too stimulating for each of them.
C. A private room close to the nursing station
Rationale: The client should not be given a private room close to the nursing station because of the high
level of activity in that area.
D. A seclusion room until the client’s activity level becomes more subdued.
Rationale: Legal and ethical guidelines require treatment in the least restrictive setting. Seclusion requires
a provider’s s order and can only be used when there is a specific, documented need to do so. [Show Less]