Chapter 10 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 10

Question 1

Type: MCSA

The nurse is documenting observations of client interactions during a group session. The nurse strives to document the behaviors of the client interactions with:

1. Objectivity.

2. Serendipity.

3. Sympathy.

4. Empathy.

Correct Answer: 1

Rationale 1: The nurse gathers data and objectively documents observations. Empathy is the ability to identify with the situation of another, and is not relative to documenting client behaviors. Sympathy is a feeling that occurs when one feels the experience as another, which can interfere with the ability to remain objective. Serendipity is not used when documenting behaviors of client interaction.

Rationale 2: The nurse gathers data and objectively documents observations. Empathy is the ability to identify with the situation of another, and is not relative to documenting client behaviors. Sympathy is a feeling that occurs when one feels the experience as another, which can interfere with the ability to remain objective. Serendipity is not used when documenting behaviors of client interaction.

Rationale 3: The nurse gathers data and objectively documents observations. Empathy is the ability to identify with the situation of another, and is not relative to documenting client behaviors. Sympathy is a feeling that occurs when one feels the experience as another, which can interfere with the ability to remain objective. Serendipity is not used when documenting behaviors of client interaction.

Rationale 4: The nurse gathers data and objectively documents observations. Empathy is the ability to identify with the situation of another, and is not relative to documenting client behaviors. Sympathy is a feeling that occurs when one feels the experience as another, which can interfere with the ability to remain objective. Serendipity is not used when documenting behaviors of client interaction.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Describe the factors that influence the process of human communication.

Question 2

Type: MCSA

The nurse is validating what was observed before documenting in the progress note. Validation is used as a mechanism to ensure which of the following?

1. The clients affect is appropriate to the situation

2. The clients perception of the response is communicated

3. The clients request is clarified

4. The clients need for further intervention is understood

Correct Answer: 2

Rationale 1: When evaluating the clients response to an intervention, the nurse validates to ensure the clients perception of the response is communicated. Affect refers to a clients emotional tone, not as a method to validate. The clients need for further intervention will be determined when the response is evaluated, not during validation of the clients response. Clarification is used when a message is not clear.

Rationale 2: When evaluating the clients response to an intervention, the nurse validates to ensure the clients perception of the response is communicated. Affect refers to a clients emotional tone, not as a method to validate. The clients need for further intervention will be determined when the response is evaluated, not during validation of the clients response. Clarification is used when a message is not clear.

Rationale 3: When evaluating the clients response to an intervention, the nurse validates to ensure the clients perception of the response is communicated. Affect refers to a clients emotional tone, not as a method to validate. The clients need for further intervention will be determined when the response is evaluated, not during validation of the clients response. Clarification is used when a message is not clear.

Rationale 4: When evaluating the clients response to an intervention, the nurse validates to ensure the clients perception of the response is communicated. Affect refers to a clients emotional tone, not as a method to validate. The clients need for further intervention will be determined when the response is evaluated, not during validation of the clients response. Clarification is used when a message is not clear.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Describe the factors that influence the process of human communication.

Question 3

Type: MCMA

Which of the following are included when documenting client education?

Standard Text: Select all that apply.

1. The educational content discussed with the client

2. The clients response

3. The purpose for the educational interaction

4. The assessment of the client

5. The nursing diagnosis

Correct Answer: 1,2,3

Rationale 1: The educational content discussed with the client. When documenting client education, the nurse documents the content discussed.

Rationale 2: The clients response. When documenting client education, the nurse documents the clients response.

Rationale 3: The purpose for the educational interaction. When documenting client education, the nurse documents the rationale for the interaction.

Rationale 4: The assessment of the client. The assessment is not part of the client education.

Rationale 5: The nursing diagnosis. The nursing diagnosis and client goal is part of the planning phase, not the intervention phase.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the factors that influence the process of human communication.

Question 4

Type: MCSA

The nurse is developing a plan of care for a client. Which of the following interventions must the nurse be careful to avoid?

1. Discussing expectations with the client

2. Selecting interventions that conflict with the clients value system

3. Identifying the clients perception of the problem

4. Addressing issues related to the clients past experiences

Correct Answer: 2

Rationale 1: In developing plans of care, the nurse avoids actions that conflict with the clients value system in order to promote communication that fosters the therapeutic relationship. The nurse utilizes information based on the nursing assessment, which includes identifying the clients perception of the problem, when developing a plan of care. The nurse involves the client in the planning process by discussing issues related to the clients experiences and discussing expectations for performance.

Rationale 2: In developing plans of care, the nurse avoids actions that conflict with the clients value system in order to promote communication that fosters the therapeutic relationship. The nurse utilizes information based on the nursing assessment, which includes identifying the clients perception of the problem, when developing a plan of care. The nurse involves the client in the planning process by discussing issues related to the clients experiences and discussing expectations for performance.

Rationale 3: In developing plans of care, the nurse avoids actions that conflict with the clients value system in order to promote communication that fosters the therapeutic relationship. The nurse utilizes information based on the nursing assessment, which includes identifying the clients perception of the problem, when developing a plan of care. The nurse involves the client in the planning process by discussing issues related to the clients experiences and discussing expectations for performance.

Rationale 4: In developing plans of care, the nurse avoids actions that conflict with the clients value system in order to promote communication that fosters the therapeutic relationship. The nurse utilizes information based on the nursing assessment, which includes identifying the clients perception of the problem, when developing a plan of care. The nurse involves the client in the planning process by discussing issues related to the clients experiences and discussing expectations for performance.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe the factors that influence the process of human communication.

Question 5

Type: MCSA

The student nurse asks why the nurse is documenting the clients nonverbal responses in addition to verbal responses during the initial assessment. Which of the following statements made by the nurse reflects the rationale for documenting both verbal and nonverbal responses?

1. It is the hospital policy to document both.

2. It is important to be thorough when documenting.

3. Documenting both permits the reader to compare the behaviors for congruence.

4. Charting verbal and nonverbal helps me remain objective.

Correct Answer: 3

Rationale 1: Both verbal and nonverbal behaviors are important to communication. The behaviors are compared to determine if the clients verbal and nonverbal communication are congruent. Nonverbal communication may carry more meaning than verbal communication. It is important to remain objective when documenting; however, the rationale for documenting both is to evaluate congruence. It is important to be thorough when documenting; however, the rationale for documenting verbal and nonverbal responses is to compare for congruence. The rationale for documenting both verbal and nonverbal is to document for congruence, not because it is or is not hospital policy.

Rationale 2: Both verbal and nonverbal behaviors are important to communication. The behaviors are compared to determine if the clients verbal and nonverbal communication are congruent. Nonverbal communication may carry more meaning than verbal communication. It is important to remain objective when documenting; however, the rationale for documenting both is to evaluate congruence. It is important to be thorough when documenting; however, the rationale for documenting verbal and nonverbal responses is to compare for congruence. The rationale for documenting both verbal and nonverbal is to document for congruence, not because it is or is not hospital policy.

Rationale 3: Both verbal and nonverbal behaviors are important to communication. The behaviors are compared to determine if the clients verbal and nonverbal communication are congruent. Nonverbal communication may carry more meaning than verbal communication. It is important to remain objective when documenting; however, the rationale for documenting both is to evaluate congruence. It is important to be thorough when documenting; however, the rationale for documenting verbal and nonverbal responses is to compare for congruence. The rationale for documenting both verbal and nonverbal is to document for congruence, not because it is or is not hospital policy.

Rationale 4: Both verbal and nonverbal behaviors are important to communication. The behaviors are compared to determine if the clients verbal and nonverbal communication are congruent. Nonverbal communication may carry more meaning than verbal communication. It is important to remain objective when documenting; however, the rationale for documenting both is to evaluate congruence. It is important to be thorough when documenting; however, the rationale for documenting verbal and nonverbal responses is to compare for congruence. The rationale for documenting both verbal and nonverbal is to document for congruence, not because it is or is not hospital policy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain why nonverbal communication is important in interpersonal relationships.

Question 6

Type: MCMA

Which of the following interventions are used by the nurse to demonstrate active listening?

Standard Text: Select all that apply.

1. Using silence

2. Covering ones mouth when yawning

3. Leaning in toward the client

4. Nodding ones head in response to clients verbal comments

5. Rocking back and forth in the chair

Correct Answer: 3,4

Rationale 1: Using silence. Using silence is a therapeutic communication technique, but not used to communicate active listening.

Rationale 2: Covering ones mouth when yawning. Covering the mouth when yawning is good manners, but does not communicate active listening.

Rationale 3: Leaning in toward the client. Leaning in is an intervention that communicates one is listening.

Rationale 4: Nodding ones head in response to clients verbal comments. Nodding ones head to a clients verbal response communicates that one is listening.

Rationale 5: Rocking back and forth in the chair. Rocking back and forth in the chair is viewed as a distraction and does not communicate openness.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain why nonverbal communication is important in interpersonal relationships.

Question 7

Type: MCSA

During a group session, the clients are asked to make one positive statement about their home life. The nurse notices that one of the clients begins to fidget in the chair and interprets this behavior as:

1. A form of nonlanguage vocalization.

2. A therapeutic use of space.

3. An expression of discomfort.

4. An excuse to avoid answering the question.

Correct Answer: 3

Rationale 1: Behavior such as fidgeting communicates an expression of discomfort; the source of the discomfort may be physical or psychological. An example of the therapeutic use of space would be to use the fidgeting as a stimulus, motivating another individual to increase the distance from the client or move away. Fidgeting is a form of body movement or kinesic communication; nonlanguage vocalizations are noises without linguistic structure. Fidgeting is a nonverbal response to a question; there is not enough data to identify if the client is trying to avoid the question; the nurse would need to engage in verbal communication to help the client identify that he or she is avoiding answering the question.

Rationale 2: Behavior such as fidgeting communicates an expression of discomfort; the source of the discomfort may be physical or psychological. An example of the therapeutic use of space would be to use the fidgeting as a stimulus, motivating another individual to increase the distance from the client or move away. Fidgeting is a form of body movement or kinesic communication; nonlanguage vocalizations are noises without linguistic structure. Fidgeting is a nonverbal response to a question; there is not enough data to identify if the client is trying to avoid the question; the nurse would need to engage in verbal communication to help the client identify that he or she is avoiding answering the question.

Rationale 3: Behavior such as fidgeting communicates an expression of discomfort; the source of the discomfort may be physical or psychological. An example of the therapeutic use of space would be to use the fidgeting as a stimulus, motivating another individual to increase the distance from the client or move away. Fidgeting is a form of body movement or kinesic communication; nonlanguage vocalizations are noises without linguistic structure. Fidgeting is a nonverbal response to a question; there is not enough data to identify if the client is trying to avoid the question; the nurse would need to engage in verbal communication to help the client identify that he or she is avoiding answering the question.

Rationale 4: Behavior such as fidgeting communicates an expression of discomfort; the source of the discomfort may be physical or psychological. An example of the therapeutic use of space would be to use the fidgeting as a stimulus, motivating another individual to increase the distance from the client or move away. Fidgeting is a form of body movement or kinesic communication; nonlanguage vocalizations are noises without linguistic structure. Fidgeting is a nonverbal response to a question; there is not enough data to identify if the client is trying to avoid the question; the nurse would need to engage in verbal communication to help the client identify that he or she is avoiding answering the question.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Explain why nonverbal communication is important in interpersonal relationships.

Question 8

Type: MCSA

During a group session, a client expresses anger at the nurse. The nurse sits tensely with arms and legs crossed while verbally agreeing that the clients point of view is correct. Which of the following messages is being sent by the nurse?

1. The nurse is expressing warmth toward the client

2. The nurse is being patient

3. The nurse is demonstrating empathy

4. The nurse is sending a mixed message

Correct Answer: 4

Rationale 1: The nurses nonverbal communication is incongruent with the verbal message; the closed body position conflicts with the open verbal statements. Because nonverbal cues help people judge the reliability of verbal messages, the incongruence between the nurses verbal and nonverbal communication may confuse the client. Patience, warmth, and empathy are positive messages that are typically expressed by using open body language.

Rationale 2: The nurses nonverbal communication is incongruent with the verbal message; the closed body position conflicts with the open verbal statements. Because nonverbal cues help people judge the reliability of verbal messages, the incongruence between the nurses verbal and nonverbal communication may confuse the client. Patience, warmth, and empathy are positive messages that are typically expressed by using open body language.

Rationale 3: The nurses nonverbal communication is incongruent with the verbal message; the closed body position conflicts with the open verbal statements. Because nonverbal cues help people judge the reliability of verbal messages, the incongruence between the nurses verbal and nonverbal communication may confuse the client. Patience, warmth, and empathy are positive messages that are typically expressed by using open body language.

Rationale 4: The nurses nonverbal communication is incongruent with the verbal message; the closed body position conflicts with the open verbal statements. Because nonverbal cues help people judge the reliability of verbal messages, the incongruence between the nurses verbal and nonverbal communication may confuse the client. Patience, warmth, and empathy are positive messages that are typically expressed by using open body language.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain why nonverbal communication is important in interpersonal relationships.

Question 9

Type: MCSA

The nurse observed that during a teaching session, the overall emotional tone of a client remained unchanged. The nurse documents this as:

1. Affect that has range.

2. Flat affect.

3. Incongruent verbal and nonverbal responses.

4. Muted behavior.

Correct Answer: 2

Rationale 1: Affect refers to the clients overall emotional tone. Flat affect is used to describe a lack of emotional tone. A client with an affect that has range is interpreted as the client demonstrating a variety of emotions. Muted behavior refers to a client who does not speak or make verbal responses. Incongruent behavior indicates the clients verbal behavior is not correlating with nonverbal behavioral responses.

Rationale 2: Affect refers to the clients overall emotional tone. Flat affect is used to describe a lack of emotional tone. A client with an affect that has range is interpreted as the client demonstrating a variety of emotions. Muted behavior refers to a client who does not speak or make verbal responses. Incongruent behavior indicates the clients verbal behavior is not correlating with nonverbal behavioral responses.

Rationale 3: Affect refers to the clients overall emotional tone. Flat affect is used to describe a lack of emotional tone. A client with an affect that has range is interpreted as the client demonstrating a variety of emotions. Muted behavior refers to a client who does not speak or make verbal responses. Incongruent behavior indicates the clients verbal behavior is not correlating with nonverbal behavioral responses.

Rationale 4: Affect refers to the clients overall emotional tone. Flat affect is used to describe a lack of emotional tone. A client with an affect that has range is interpreted as the client demonstrating a variety of emotions. Muted behavior refers to a client who does not speak or make verbal responses. Incongruent behavior indicates the clients verbal behavior is not correlating with nonverbal behavioral responses.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain why nonverbal communication is important in interpersonal relationships.

Question 10

Type: MCSA

The nurse is working with a teen admitted with a diagnosis of depression. Which of the following interventions demonstrates that the nurse is sensitive to the clients needs?

1. Avoiding the use of silence to decrease anxiety

2. Asking for details to demonstrate interest in the client

3. Using closed-ended questions

4. Listening to the clients feelings

Correct Answer: 4

Rationale 1: Listening to the clients feelings helps to communicate the clients value and is part of demonstrating sensitivity to the client. Closed-ended questions limit the quality of the clients responses, minimizing opportunity for the client to explore feelings or to develop insight. Avoiding the use of silence does not decrease anxiety, but is often a response to anxiety.

Rationale 2: Listening to the clients feelings helps to communicate the clients value and is part of demonstrating sensitivity to the client. Closed-ended questions limit the quality of the clients responses, minimizing opportunity for the client to explore feelings or to develop insight. Avoiding the use of silence does not decrease anxiety, but is often a response to anxiety.

Rationale 3: Listening to the clients feelings helps to communicate the clients value and is part of demonstrating sensitivity to the client. Closed-ended questions limit the quality of the clients responses, minimizing opportunity for the client to explore feelings or to develop insight. Avoiding the use of silence does not decrease anxiety, but is often a response to anxiety.

Rationale 4: Listening to the clients feelings helps to communicate the clients value and is part of demonstrating sensitivity to the client. Closed-ended questions limit the quality of the clients responses, minimizing opportunity for the client to explore feelings or to develop insight. Avoiding the use of silence does not decrease anxiety, but is often a response to anxiety.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify the principles of therapeutic communication and explain why they are essential ingredients of interpersonal relationships.

Question 11

Type: MCSA

A working goal for the nurseclient relationship is to achieve:

1. Facilitative intimacy.

2. Self-disclosure.

3. Interdependence.

4. Social superficiality.

Correct Answer: 1

Rationale 1: When the nurseclient relationship achieves facilitative intimacy, the relationship moves from the social realm to addressing meaningful areas of concern for the client. Social superficiality usually occurs at the beginning of a relationship. Self-disclosure occurs when the individuals share information about themselves. Social relationships are characterized by interdependence; in the nurseclient relationship, the desire is to move the client toward independence.

Rationale 2: When the nurseclient relationship achieves facilitative intimacy, the relationship moves from the social realm to addressing meaningful areas of concern for the client. Social superficiality usually occurs at the beginning of a relationship. Self-disclosure occurs when the individuals share information about themselves. Social relationships are characterized by interdependence; in the nurseclient relationship, the desire is to move the client toward independence.

Rationale 3: When the nurseclient relationship achieves facilitative intimacy, the relationship moves from the social realm to addressing meaningful areas of concern for the client. Social superficiality usually occurs at the beginning of a relationship. Self-disclosure occurs when the individuals share information about themselves. Social relationships are characterized by interdependence; in the nurseclient relationship, the desire is to move the client toward independence.

Rationale 4: When the nurseclient relationship achieves facilitative intimacy, the relationship moves from the social realm to addressing meaningful areas of concern for the client. Social superficiality usually occurs at the beginning of a relationship. Self-disclosure occurs when the individuals share information about themselves. Social relationships are characterized by interdependence; in the nurseclient relationship, the desire is to move the client toward independence.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Identify the principles of therapeutic communication and explain why they are essential ingredients of interpersonal relationships.

Question 12

Type: MCSA

During the first interaction with a client, the nurse makes an introduction and identifies the purpose of the interaction. This serves to accomplish which of the following in developing a trusting relationship?

1. Setting goals

2. Building

3. Initiating

4. Maintaining

Correct Answer: 3

Rationale 1: The initiation phase occurs at the beginning of the relationship. Building occurs as participants establish mutual goals. The relationship is maintained as participants work together. Goals are established to provide direction and purpose.

Rationale 2: The initiation phase occurs at the beginning of the relationship. Building occurs as participants establish mutual goals. The relationship is maintained as participants work together. Goals are established to provide direction and purpose.

Rationale 3: The initiation phase occurs at the beginning of the relationship. Building occurs as participants establish mutual goals. The relationship is maintained as participants work together. Goals are established to provide direction and purpose.

Rationale 4: The initiation phase occurs at the beginning of the relationship. Building occurs as participants establish mutual goals. The relationship is maintained as participants work together. Goals are established to provide direction and purpose.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify the principles of therapeutic communication and explain why they are essential ingredients of interpersonal relationships.

Question 13

Type: MCSA

The nurse engaged in a therapeutic relationship with a client uses nonverbal communication to:

1. Enhance verbal messages.

2. Avoid the use of verbal messages.

3. Detract from verbal messages.

4. Terminate the therapeutic relationship.

Correct Answer: 1

Rationale 1: Nonverbal messages should enhance, not detract from verbal messages. Nonverbal communication is used to clarify or accentuate verbal messages, not to avoid their use. Nonverbal communication is not used to terminate a therapeutic relationship.

Rationale 2: Nonverbal messages should enhance, not detract from verbal messages. Nonverbal communication is used to clarify or accentuate verbal messages, not to avoid their use. Nonverbal communication is not used to terminate a therapeutic relationship.

Rationale 3: Nonverbal messages should enhance, not detract from verbal messages. Nonverbal communication is used to clarify or accentuate verbal messages, not to avoid their use. Nonverbal communication is not used to terminate a therapeutic relationship.

Rationale 4: Nonverbal messages should enhance, not detract from verbal messages. Nonverbal communication is used to clarify or accentuate verbal messages, not to avoid their use. Nonverbal communication is not used to terminate a therapeutic relationship.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify the principles of therapeutic communication and explain why they are essential ingredients of interpersonal relationships.

Question 14

Type: MCSA

A nurse acknowledges feeling anxious about meeting new people. By acknowledging feelings to the client, the nurse is demonstrating:

1. Sympathy.

2. Genuineness.

3. Empathy.

4. Superficiality.

Correct Answer: 2

Rationale 1: The active component of genuineness requires one to be honest with another; an example of this is the nurse acknowledging feelings of anxiety to a client.

Rationale 2: The active component of genuineness requires one to be honest with another; an example of this is the nurse acknowledging feelings of anxiety to a client.

Rationale 3: The active component of genuineness requires one to be honest with another; an example of this is the nurse acknowledging feelings of anxiety to a client.

Rationale 4: The active component of genuineness requires one to be honest with another; an example of this is the nurse acknowledging feelings of anxiety to a client.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify the principles of therapeutic communication and explain why they are essential ingredients of interpersonal relationships.

Question 15

Type: MCSA

Psychiatricmental health nursing interventions occur at which of the following levels of communication?

1. Public

2. Intrapersonal

3. Interpersonal

4. International

Correct Answer: 3

Rationale 1: Psychiatricmental health nursing interventions primarily occur at the interpersonal level. The interpersonal level refers to one person communicating with another. Intrapersonal communication occurs when one communicates with oneself. Public communication occurs when communicating with large numbers of people. International communication is a form of public communication.

Rationale 2: Psychiatricmental health nursing interventions primarily occur at the interpersonal level. The interpersonal level refers to one person communicating with another. Intrapersonal communication occurs when one communicates with oneself. Public communication occurs when communicating with large numbers of people. International communication is a form of public communication.

Rationale 3: Psychiatricmental health nursing interventions primarily occur at the interpersonal level. The interpersonal level refers to one person communicating with another. Intrapersonal communication occurs when one communicates with oneself. Public communication occurs when communicating with large numbers of people. International communication is a form of public communication.

Rationale 4: Psychiatricmental health nursing interventions primarily occur at the interpersonal level. The interpersonal level refers to one person communicating with another. Intrapersonal communication occurs when one communicates with oneself. Public communication occurs when communicating with large numbers of people. International communication is a form of public communication.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate a strategy for improving your personal ability to communicate therapeutically.

Question 16

Type: MCSA

In planning care for a client who is gaining mental stability, the nurse develops measures to confirm the clients view of self. Which of the following responses made by the nurse would be categorized as disturbed communication?

1. I do not understand what you are telling me.

2. You are wrong.

3. How might you go about that differently?

4. Do you want to try that again?

Correct Answer: 2

Rationale 1: Telling clients that they are wrong is an example of rejection. Communication that rejects the others sense of self creates a disturbance in communication and can affect the relationship. Indicating that the nurse does not understand what is being said communicates information about the message, not the individual. Asking if the client wants to try again provides the client with control. Asking how the client might do something differently encourages the client to develop another plan, focusing on the action and not the individual.

Rationale 2: Telling clients that they are wrong is an example of rejection. Communication that rejects the others sense of self creates a disturbance in communication and can affect the relationship. Indicating that the nurse does not understand what is being said communicates information about the message, not the individual. Asking if the client wants to try again provides the client with control. Asking how the client might do something differently encourages the client to develop another plan, focusing on the action and not the individual.

Rationale 3: Telling clients that they are wrong is an example of rejection. Communication that rejects the others sense of self creates a disturbance in communication and can affect the relationship. Indicating that the nurse does not understand what is being said communicates information about the message, not the individual. Asking if the client wants to try again provides the client with control. Asking how the client might do something differently encourages the client to develop another plan, focusing on the action and not the individual.

Rationale 4: Telling clients that they are wrong is an example of rejection. Communication that rejects the others sense of self creates a disturbance in communication and can affect the relationship. Indicating that the nurse does not understand what is being said communicates information about the message, not the individual. Asking if the client wants to try again provides the client with control. Asking how the client might do something differently encourages the client to develop another plan, focusing on the action and not the individual.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate a strategy for improving your personal ability to communicate therapeutically.

Question 17

Type: MCSA

Which of the following communication theories provides the most appropriate rationale for a nursing intervention to utilize the perceived strengths of the client in promoting effective communication?

1. Behavioral Effects and Human Communication Theory

2. Neurolinguistic Programming Theory

3. Theory of Communication Levels

4. Therapeutic Communication Theory

Correct Answer: 4

Rationale 1: Therapeutic Communication Theory (TCT) includes all the processes by which one human being influences another, taking into account the perceptions and interpretations that influence one persons view of the other.

Rationale 2: Therapeutic Communication Theory (TCT) includes all the processes by which one human being influences another, taking into account the perceptions and interpretations that influence one persons view of the other.

Rationale 3: Therapeutic Communication Theory (TCT) includes all the processes by which one human being influences another, taking into account the perceptions and interpretations that influence one persons view of the other.

Rationale 4: Therapeutic Communication Theory (TCT) includes all the processes by which one human being influences another, taking into account the perceptions and interpretations that influence one persons view of the other.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate a strategy for improving your personal ability to communicate therapeutically.

Question 18

Type: MCSA

Which of the following is not related to the theory of successful versus disturbed communication patterns during an admission assessment?

1. The appropriateness of the content of the message.

2. The quality of the feedback provided.

3. The language level of the assessment nurse.

4. How efficiently the client delivers a message.

Correct Answer: 3

Rationale 1: During the assessment, the nurse is attending to the clients response; therefore, the language level of the nurse is not relative. The language level used by the nurse is a stimulus for the response of the client.

Rationale 2: During the assessment, the nurse is attending to the clients response; therefore, the language level of the nurse is not relative. The language level used by the nurse is a stimulus for the response of the client.

Rationale 3: During the assessment, the nurse is attending to the clients response; therefore, the language level of the nurse is not relative. The language level used by the nurse is a stimulus for the response of the client.

Rationale 4: During the assessment, the nurse is attending to the clients response; therefore, the language level of the nurse is not relative. The language level used by the nurse is a stimulus for the response of the client.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Formulate a strategy for improving your personal ability to communicate therapeutically.

Question 19

Type: MCSA

A client asks the nurse about the doctors comment that he may have problems due to delayed synaptic transmission in his brain. The nurse explains that the best way to describe a synaptic transmission is which of the following?

1. An electrochemical process called neurotransmission

2. Where the axon is released

3. When the receptors bind to neurons

4. The space where neurotransmitters match up with receptors

Correct Answer: 1

Rationale 1: In the Neurobiologic Factor Model, the neurons of the brain are responsible for information processing. Neurotransmission is the electrochemical process that explains how the messages move through the communication circuit. Neurotransmission is a process, not a space where the transmitters match up, when receptors bind to neurons, or where the axon is released.

Rationale 2: In the Neurobiologic Factor Model, the neurons of the brain are responsible for information processing. Neurotransmission is the electrochemical process that explains how the messages move through the communication circuit. Neurotransmission is a process, not a space where the transmitters match up, when receptors bind to neurons, or where the axon is released.

Rationale 3: In the Neurobiologic Factor Model, the neurons of the brain are responsible for information processing. Neurotransmission is the electrochemical process that explains how the messages move through the communication circuit. Neurotransmission is a process, not a space where the transmitters match up, when receptors bind to neurons, or where the axon is released.

Rationale 4: In the Neurobiologic Factor Model, the neurons of the brain are responsible for information processing. Neurotransmission is the electrochemical process that explains how the messages move through the communication circuit. Neurotransmission is a process, not a space where the transmitters match up, when receptors bind to neurons, or where the axon is released.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate a strategy for improving your personal ability to communicate therapeutically.

Question 20

Type: MCSA

A client is admitted to the psychiatric unit exhibiting behaviors indicating a high level of anxiety following a personal crisis. Which of the following communication skills should the nurse utilize when interacting with this client?

1. Closed-ended questions

2. Providing reassurance

3. Open-ended questions

4. Providing the client with advice

Correct Answer: 1

Rationale 1: Closed-ended questions are indicated at this point in time. When communicating with a client in a state of high anxiety, the nurse utilizes communication techniques that do not require the client to engage in reflection or problem solving, as this will cause more anxiety. Open-ended questions will be appropriate once the client is more stable. Providing reassurance and providing advice are not therapeutic in this situation.

Rationale 2: Closed-ended questions are indicated at this point in time. When communicating with a client in a state of high anxiety, the nurse utilizes communication techniques that do not require the client to engage in reflection or problem solving, as this will cause more anxiety. Open-ended questions will be appropriate once the client is more stable. Providing reassurance and providing advice are not therapeutic in this situation.

Rationale 3: Closed-ended questions are indicated at this point in time. When communicating with a client in a state of high anxiety, the nurse utilizes communication techniques that do not require the client to engage in reflection or problem solving, as this will cause more anxiety. Open-ended questions will be appropriate once the client is more stable. Providing reassurance and providing advice are not therapeutic in this situation.

Rationale 4: Closed-ended questions are indicated at this point in time. When communicating with a client in a state of high anxiety, the nurse utilizes communication techniques that do not require the client to engage in reflection or problem solving, as this will cause more anxiety. Open-ended questions will be appropriate once the client is more stable. Providing reassurance and providing advice are not therapeutic in this situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Employ the skills discussed here to foster relationships and communication in the psychiatricmental health setting.

Question 21

Type: MCSA

During a nurseclient interaction, the client tells the nurse, I dont think I can deal with feeling so sad much longer. The nurses best response is which of the following?

1. Is there a history of depression in your family?

2. We all have times of sadness.

3. Are you saying you feel sad?

4. Tell me about your feelings of sadness.

Correct Answer: 4

Rationale 1: The nurse is using the therapeutic communication technique of encouraging the client to explore feelings when asking the client to talk about the feelings of sadness. The technique of reflecting You feel sad? is therapeutic, but the better response is to encourage the client to explore the feelings about being sad to facilitate developing insight. Restating at this point would prompt a closed-ended response by focusing on the content (sad), as opposed to focusing on the behavior or feelings (sadness). Asking about the clients history provides the client with an opportunity to shift the focus from the feelings to providing information about the clients family; the nurse should review the clients history prior to the interaction. Suggesting that we all have times of sadness discounts the clients feelings.

Rationale 2: The nurse is using the therapeutic communication technique of encouraging the client to explore feelings when asking the client to talk about the feelings of sadness. The technique of reflecting You feel sad? is therapeutic, but the better response is to encourage the client to explore the feelings about being sad to facilitate developing insight. Restating at this point would prompt a closed-ended response by focusing on the content (sad), as opposed to focusing on the behavior or feelings (sadness). Asking about the clients history provides the client with an opportunity to shift the focus from the feelings to providing information about the clients family; the nurse should review the clients history prior to the interaction. Suggesting that we all have times of sadness discounts the clients feelings.

Rationale 3: The nurse is using the therapeutic communication technique of encouraging the client to explore feelings when asking the client to talk about the feelings of sadness. The technique of reflecting You feel sad? is therapeutic, but the better response is to encourage the client to explore the feelings about being sad to facilitate developing insight. Restating at this point would prompt a closed-ended response by focusing on the content (sad), as opposed to focusing on the behavior or feelings (sadness). Asking about the clients history provides the client with an opportunity to shift the focus from the feelings to providing information about the clients family; the nurse should review the clients history prior to the interaction. Suggesting that we all have times of sadness discounts the clients feelings.

Rationale 4: The nurse is using the therapeutic communication technique of encouraging the client to explore feelings when asking the client to talk about the feelings of sadness. The technique of reflecting You feel sad? is therapeutic, but the better response is to encourage the client to explore the feelings about being sad to facilitate developing insight. Restating at this point would prompt a closed-ended response by focusing on the content (sad), as opposed to focusing on the behavior or feelings (sadness). Asking about the clients history provides the client with an opportunity to shift the focus from the feelings to providing information about the clients family; the nurse should review the clients history prior to the interaction. Suggesting that we all have times of sadness discounts the clients feelings.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Employ the skills discussed here to foster relationships and communication in the psychiatricmental health setting.

Question 22

Type: MCSA

While reviewing therapeutic communication techniques, a nursing student made a list of things not to do or say to a client. Which of the following comments should be on the students list?

1. How do you feel about being discharged today?

2. What happened when you quit taking your medications?

3. What are your concerns about your living situation?

4. Why do you think you will never get well?

Correct Answer: 4

Rationale 1: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. Asking the client Why do you think you will never get well? is an example of requesting an explanation, which is not therapeutic and requires the client to defend his or her actions. Asking how the client feels about being discharged, what happened when medication was discontinued, or concerns about the clients living situation are examples of therapeutic communication.

Rationale 2: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. Asking the client Why do you think you will never get well? is an example of requesting an explanation, which is not therapeutic and requires the client to defend his or her actions. Asking how the client feels about being discharged, what happened when medication was discontinued, or concerns about the clients living situation are examples of therapeutic communication.

Rationale 3: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. Asking the client Why do you think you will never get well? is an example of requesting an explanation, which is not therapeutic and requires the client to defend his or her actions. Asking how the client feels about being discharged, what happened when medication was discontinued, or concerns about the clients living situation are examples of therapeutic communication.

Rationale 4: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. Asking the client Why do you think you will never get well? is an example of requesting an explanation, which is not therapeutic and requires the client to defend his or her actions. Asking how the client feels about being discharged, what happened when medication was discontinued, or concerns about the clients living situation are examples of therapeutic communication.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Employ the skills discussed here to foster relationships and communication in the psychiatricmental health setting.

Question 23

Type: MCSA

A client states, I just know my brother will not come back from the war. Which of the following examples would be used to encourage the client to explore this concern?

1. Maybe he will be one of the lucky ones.

2. How do you know this?

3. Where is your brother going?

4. What do you feel will happen to him?

Correct Answer: 4

Rationale 1: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. It is therapeutic at this point to encourage the client to explore feelings. Asking where the brother is going is not therapeutic as this question prompts an informational response as opposed to encouraging the client to explore feelings about the situation. Stating the brother may be one of the lucky ones is an example of a stereotypical comment that closes the communication loop. Asking how the client knows the brother will not return is an example of requesting an explanation, which is not therapeutic.

Rationale 2: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. It is therapeutic at this point to encourage the client to explore feelings. Asking where the brother is going is not therapeutic as this question prompts an informational response as opposed to encouraging the client to explore feelings about the situation. Stating the brother may be one of the lucky ones is an example of a stereotypical comment that closes the communication loop. Asking how the client knows the brother will not return is an example of requesting an explanation, which is not therapeutic.

Rationale 3: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. It is therapeutic at this point to encourage the client to explore feelings. Asking where the brother is going is not therapeutic as this question prompts an informational response as opposed to encouraging the client to explore feelings about the situation. Stating the brother may be one of the lucky ones is an example of a stereotypical comment that closes the communication loop. Asking how the client knows the brother will not return is an example of requesting an explanation, which is not therapeutic.

Rationale 4: Therapeutic communication skills are used to foster the nurseclient relationship in the psychiatricmental health setting. It is therapeutic at this point to encourage the client to explore feelings. Asking where the brother is going is not therapeutic as this question prompts an informational response as opposed to encouraging the client to explore feelings about the situation. Stating the brother may be one of the lucky ones is an example of a stereotypical comment that closes the communication loop. Asking how the client knows the brother will not return is an example of requesting an explanation, which is not therapeutic.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Employ the skills discussed here to foster relationships and communication in the psychiatricmental health setting.

Question 24

Type: MCSA

Which of the following is an example of clarifying a clients verbal response?

1. Are you saying you feel the medicine is helping you?

2. See, the medicine does work.

3. I knew it would work; it just takes time.

4. Everything seems to work out eventually.

Correct Answer: 1

Rationale 1: Asking if the client thinks the medicine is helping is an example of clarifying, which is therapeutic. I knew it would work; it just takes time and Everything seems to work out eventually are examples of making stereotypical comments and do not provide the client with a sense that the nurse was listening. See, the medicine does work communicates a lack of trust and is not therapeutic.

Rationale 2: Asking if the client thinks the medicine is helping is an example of clarifying, which is therapeutic. I knew it would work; it just takes time and Everything seems to work out eventually are examples of making stereotypical comments and do not provide the client with a sense that the nurse was listening. See, the medicine does work communicates a lack of trust and is not therapeutic.

Rationale 3: Asking if the client thinks the medicine is helping is an example of clarifying, which is therapeutic. I knew it would work; it just takes time and Everything seems to work out eventually are examples of making stereotypical comments and do not provide the client with a sense that the nurse was listening. See, the medicine does work communicates a lack of trust and is not therapeutic.

Rationale 4: Asking if the client thinks the medicine is helping is an example of clarifying, which is therapeutic. I knew it would work; it just takes time and Everything seems to work out eventually are examples of making stereotypical comments and do not provide the client with a sense that the nurse was listening. See, the medicine does work communicates a lack of trust and is not therapeutic.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Employ the skills discussed here to foster relationships and communication in the psychiatricmental health setting.

Question 25

Type: MCSA

A delusional client walks up to the nurse and says, I am the appointed overseer. Who are you and why are you here? The most therapeutic response is which of the following?

1. I am your nurse and I will be here to help you until suppertime.

2. You dont know who I am?

3. You know who I am.

4. You are not the overseer; you are a client in the hospital.

Correct Answer: 1

Rationale 1: Responding with I am your nurse is an example of giving information; the nurse responds to the clients request without getting into a confrontation and conveys respect. The responses either asking if the client knows who the nurse is, or stating that the client knows the nurse are not therapeutic and may be perceived as challenging to the client. Stating that the client is not the overseer and reminding the client of inpatient status provides the client with information and presents reality, but the information does not provide the client with a response to the question, Who are you and why are you here?

Rationale 2: Responding with I am your nurse is an example of giving information; the nurse responds to the clients request without getting into a confrontation and conveys respect. The responses either asking if the client knows who the nurse is, or stating that the client knows the nurse are not therapeutic and may be perceived as challenging to the client. Stating that the client is not the overseer and reminding the client of inpatient status provides the client with information and presents reality, but the information does not provide the client with a response to the question, Who are you and why are you here?

Rationale 3: Responding with I am your nurse is an example of giving information; the nurse responds to the clients request without getting into a confrontation and conveys respect. The responses either asking if the client knows who the nurse is, or stating that the client knows the nurse are not therapeutic and may be perceived as challenging to the client. Stating that the client is not the overseer and reminding the client of inpatient status provides the client with information and presents reality, but the information does not provide the client with a response to the question, Who are you and why are you here?

Rationale 4: Responding with I am your nurse is an example of giving information; the nurse responds to the clients request without getting into a confrontation and conveys respect. The responses either asking if the client knows who the nurse is, or stating that the client knows the nurse are not therapeutic and may be perceived as challenging to the client. Stating that the client is not the overseer and reminding the client of inpatient status provides the client with information and presents reality, but the information does not provide the client with a response to the question, Who are you and why are you here?

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Employ the skills discussed here to foster relationships and communication in the psychiatricmental health setting.

Question 26

Type: MCSA

Which of the following interventions promotes mindful listening in any health care setting?

1. Telling the client to get off the phone

2. Encouraging the family to step outside before assessing the client

3. Turning off the television before interviewing a client

4. Asking clients what they would like to drink when taking medication

Correct Answer: 3

Rationale 1: Mindful listening is best accomplished when removing environmental distractions, such as turning off the television before interviewing a client. Asking clients what they would like to drink when taking medication and encouraging the family to step outside before assessing the client are examples of conveying respect. Telling the client to get off the phone is not a therapeutic intervention.

Rationale 2: Mindful listening is best accomplished when removing environmental distractions, such as turning off the television before interviewing a client. Asking clients what they would like to drink when taking medication and encouraging the family to step outside before assessing the client are examples of conveying respect. Telling the client to get off the phone is not a therapeutic intervention.

Rationale 3: Mindful listening is best accomplished when removing environmental distractions, such as turning off the television before interviewing a client. Asking clients what they would like to drink when taking medication and encouraging the family to step outside before assessing the client are examples of conveying respect. Telling the client to get off the phone is not a therapeutic intervention.

Rationale 4: Mindful listening is best accomplished when removing environmental distractions, such as turning off the television before interviewing a client. Asking clients what they would like to drink when taking medication and encouraging the family to step outside before assessing the client are examples of conveying respect. Telling the client to get off the phone is not a therapeutic intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain how the skills discussed here foster relating and communicating in any health care setting.

Question 27

Type: MCSA

In the immunization clinic, the nurse notices a client displaying tense body posture. Which of the following is the most therapeutic response for the nurse to make?

1. This wont hurt a bit.

2. You need to relax.

3. I can tell youve had a bad experience before.

4. I notice you are clenching your fists.

Correct Answer: 4

Rationale 1: The nurses observation about clenched fists is a therapeutic intervention, which conveys the nurse is attending to the nonverbal cues of the client. Making an assumption that the client has had a bad experience before is not therapeutic. Telling the client that the immunization will not hurt is offering false reassurance. Directing the client to relax is a form of giving advice, which is not therapeutic.

Rationale 2: The nurses observation about clenched fists is a therapeutic intervention, which conveys the nurse is attending to the nonverbal cues of the client. Making an assumption that the client has had a bad experience before is not therapeutic. Telling the client that the immunization will not hurt is offering false reassurance. Directing the client to relax is a form of giving advice, which is not therapeutic.

Rationale 3: The nurses observation about clenched fists is a therapeutic intervention, which conveys the nurse is attending to the nonverbal cues of the client. Making an assumption that the client has had a bad experience before is not therapeutic. Telling the client that the immunization will not hurt is offering false reassurance. Directing the client to relax is a form of giving advice, which is not therapeutic.

Rationale 4: The nurses observation about clenched fists is a therapeutic intervention, which conveys the nurse is attending to the nonverbal cues of the client. Making an assumption that the client has had a bad experience before is not therapeutic. Telling the client that the immunization will not hurt is offering false reassurance. Directing the client to relax is a form of giving advice, which is not therapeutic.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain how the skills discussed here foster relating and communicating in any health care setting.

Question 28

Type: MCSA

The nurse gathering data from a client admitted to labor and delivery is overheard making the comment, You are lying. You need to tell me the truth so we can do what is best for your baby. The nurses communication is:

1. A perception check.

2. Nontherapeutic.

3. Necessary.

4. Therapeutic.

Correct Answer: 2

Rationale 1: During admission, the nurse should engage in active listening. This nurse is making an accusatory statement that is nontherapeutic, unnecessary, and will result in a defensive response from the client. This is not a perception check; a perception check provides the client with the opportunity to correct inaccurate perceptions.

Rationale 2: During admission, the nurse should engage in active listening. This nurse is making an accusatory statement that is nontherapeutic, unnecessary, and will result in a defensive response from the client. This is not a perception check; a perception check provides the client with the opportunity to correct inaccurate perceptions.

Rationale 3: During admission, the nurse should engage in active listening. This nurse is making an accusatory statement that is nontherapeutic, unnecessary, and will result in a defensive response from the client. This is not a perception check; a perception check provides the client with the opportunity to correct inaccurate perceptions.

Rationale 4: During admission, the nurse should engage in active listening. This nurse is making an accusatory statement that is nontherapeutic, unnecessary, and will result in a defensive response from the client. This is not a perception check; a perception check provides the client with the opportunity to correct inaccurate perceptions.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain how the skills discussed here foster relating and communicating in any health care setting.

Question 29

Type: MCSA

When considering communication skills, the nurse caring for an older client anticipates that the client will:

1. Interrupt frequently.

2. Take longer to respond.

3. Answer questions with one-word responses.

4. Remain silent.

Correct Answer: 2

Rationale 1: Elder clients may take longer to respond due to cognitive and neurological delays. The client manifesting muted communication is more likely to respond using one-word responses or remain silent. Elder clients may or may not interrupt or remain silent.

Rationale 2: Elder clients may take longer to respond due to cognitive and neurological delays. The client manifesting muted communication is more likely to respond using one-word responses or remain silent. Elder clients may or may not interrupt or remain silent.

Rationale 3: Elder clients may take longer to respond due to cognitive and neurological delays. The client manifesting muted communication is more likely to respond using one-word responses or remain silent. Elder clients may or may not interrupt or remain silent.

Rationale 4: Elder clients may take longer to respond due to cognitive and neurological delays. The client manifesting muted communication is more likely to respond using one-word responses or remain silent. Elder clients may or may not interrupt or remain silent.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain how the skills discussed here foster relating and communicating in any health care setting.

Question 30

Type: MCSA

The nurse is admitting a client from the emergency room. Which of the following would be used to clarify the nurses understanding of the clients chief complaint?

1. If you are bleeding, where is the blood?

2. I feel your pain when I see you hold your side.

3. Are you saying you feel that you are bleeding inside?

4. Dont worry; we have the technology to take care of you.

Correct Answer: 3

Rationale 1: Asking if the client feels there is internal bleeding seeks to clarify the clients complaint. Telling the client not to worry is an example of minimizing, it discounts the clients feelings, and is not therapeutic. Stating that the nurse feels the clients pain may be therapeutic but does not clarify the clients complaint. Demanding that the client show the blood is a form of challenging which may put the client on the defensive and does not clarify the clients complaint.

Rationale 2: Asking if the client feels there is internal bleeding seeks to clarify the clients complaint. Telling the client not to worry is an example of minimizing, it discounts the clients feelings, and is not therapeutic. Stating that the nurse feels the clients pain may be therapeutic but does not clarify the clients complaint. Demanding that the client show the blood is a form of challenging which may put the client on the defensive and does not clarify the clients complaint.

Rationale 3: Asking if the client feels there is internal bleeding seeks to clarify the clients complaint. Telling the client not to worry is an example of minimizing, it discounts the clients feelings, and is not therapeutic. Stating that the nurse feels the clients pain may be therapeutic but does not clarify the clients complaint. Demanding that the client show the blood is a form of challenging which may put the client on the defensive and does not clarify the clients complaint.

Rationale 4: Asking if the client feels there is internal bleeding seeks to clarify the clients complaint. Telling the client not to worry is an example of minimizing, it discounts the clients feelings, and is not therapeutic. Stating that the nurse feels the clients pain may be therapeutic but does not clarify the clients complaint. Demanding that the client show the blood is a form of challenging which may put the client on the defensive and does not clarify the clients complaint.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain how the skills discussed here foster relating and communicating in any health care setting.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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