RN HESI Exit – Saunders | Psych/Mental Health Exit | Questions, Answers, and Rationale
The home care nurse is visiting an older client whose spouse
... [Show More] died 6 months ago. Which
behavior by the client indicates ineffective coping?
1. Neglecting personal grooming
2. Looking at old snapshots of family
3. Participating in a senior citizens' program
4. Visiting their spouse's grave once a month ------Correct Answer------1. Neglecting
personal grooming
Rational:
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to
a death, ineffective coping is manifested by an extreme behavior that in some cases
may be harmful to the individual physically or psychologically. The correct option is
indicative of a behavior that identifies an ineffective coping behavior in the grieving
process.
A client with a diagnosis of major 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."
Which response demonstrates therapeutic communication?
1. "You have everything to live for."
2. "Why do you see yourself as a failure?"
3. "Feeling like this is all part of being depressed."
4. "You've been feeling like a failure for a while?" ------Correct Answer------4. "You've
been feeling like a failure for a while?"
Rationale:
Responding to the feelings expressed by a client is an effective therapeutic
communication technique. The correct option is an example of the use of restating. The
remaining options block communication because they minimize the client's experience
and do not facilitate exploration of the client's expressed feelings. In addition, use of the
word "why" is nontherapeutic.
When the mental health nurse visits a client at home, the client states, "I haven't slept at
all the last couple of nights." Which response by the nurse illustrates a therapeutic
communication response to this client?
1. "I see."
2. "Really?"
3. "You're having difficulty sleeping?"
4. "Sometimes, I have trouble sleeping too." ------Correct Answer------3. "You're having
difficulty sleeping?"
Rationale:
The correct option uses the therapeutic communication technique of restatement.
Although restatement is a technique that has a prompting component to it, it repeats the
client's major theme, which assists the nurse to obtain a more specific perception of the
problem from the client. The remaining options are not therapeutic responses since
none encourage the client to expand on the problem. Offering personal experiences
moves the focus away from the client and onto the nurse. [Show Less]