1. Answer: A. Check on the client frequently at irregular intervals throughout the night

Rationale: Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. Option B may encourage the client to try to manipulate the nurse’s or seek attention for having a secret suicide plan. Option C may reinforce a suicidal idea. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn’t disregard it.

  1. Answer: C. This must be difficult for you and your mother.

            Rationale: Acknowledging the feeling of the patient allows the nurse to convey that she understands what the patient is going through. This also helps to enhance the communication between the nurse and the patient, allowing exploration of other underlying thoughts and issues. Option A invalidates the feelings of the patient while Options B and D suggests actions that the patient must take without properly assessing the situation first.

  1. Answer: B. “You told me you got fired from your past job for missing too many days after taking drugs all night.”

Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn’t an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussing should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.

  1. Answer: C. Identify anxiety-causing situations

Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situation as that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn’t a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn’t a realistic goal early in treatment.

  1. Answer: C. “I just can’t seem to get down to the weight I want to be. I’m so fat compared to other girls.”

Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a “desirable weight” is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don’t like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be other weight when she looks in the mirror. Proffering fast food over health food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in this client with anorexia nervosa.

  1. Answer: B. Are you planning to commit suicide?

            Rationale: Depressed patients who have suicidal tendencies need to be asked directly whether they are planning to commit suicide and how they plan to do it. This allows the nurse to plan care effectively and establish a no-harm contract with the patient. Giving away of prized possessions is usually an indication of a plan to take one’s life. Options A, C and D are not the correct questions to ask a suicidal patient.

  1. Answer: C. I want to help you, not harm you. It must be frightening thinking people want to hurt you.

            Rationale: The best therapeutic communication with a schizophrenic patient is to acknowledge their fears while also developing rapport with the patient as a nurse. This statement best meets those needs.

A patient with schizophrenia will truly believe in the statements they are making, so the nurse should not try to convince the patient they are wrong as this may develop distrust between the nurse and patient. The focus should remain on the patient and their beliefs. The nurse should not bring other patients into the conversation. As to answer option d, this statement does not acknowledge that the patient’s thoughts are their reality. The patient may also not know the answer to this question and the nurse will not be able to develop rapport with the patient.

  1. Answer: A. Antisocial personality disorder

Rationale: The client’s history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can’t control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.

  1. Answer: D. “You’ve been feeling like a failure for a while?”

Rationale: Responding to the feelings expressed by a patient 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 patient’s experience and do not facilitate exploration of the patient’s expressed feelings. In additions, use of the word “why” is nontherapeutic.

  1. Answer: A. Using open-ended questions and silence

Rationale: Open-ended questions and silence are strategies use to encourage patients to discuss their problems. Sharing personal food preferences is not a patient-centered intervention. The remaining options are not helpful to the patient because they do not encourage the patient to express feelings. The nurse should not offer opinions and should encourage the patient to identify the reasons for the behavior.

  1. Answer: A. Denial

Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the patient to return to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.

  1. Answer: D. A willingness to participate in the planning of the care and treatment plan.

Rationale: In general, patients seek voluntary admission. If a patient seeks voluntary admission, the most likely expectations is the patient will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a patients understanding of their illness, only of their desire for help.

  1. Answer: A. Contact the patients health care provider (HCP)

Rationale: In general, patients seek, voluntary admission. Voluntary patients have the right to demand and obtain release. The nurse needs ot be familiar with the state and facility policies and procedures. The best nursing action is to contact the HCP, who has the authority to discuss discharge with the patient. While arranging for safe transportation is appropriate it is premature in this situation and should be done only with the patients’ permission. While it is appropriate to discuss why the patient feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the patient to agree to staying “a few more days” has little value and will not likely be successful. Many states require that the patient submit a written release notice to the facility staff members, who reevaluate the patient’s condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat to the patient.

  1. Answer: D. Inquiring about and examining the patient’s feelings for any that may block adaptive coping

Rationale: The patient must first deal with feelings and negative responses before the patient can work through the meaning the crisis. The correct option pertains directly to the patient’s feelings and is patient-focused. The remaining options do not directly focus on or address the patient’s feelings.

  1. Answer: B. mixed.

Rationale: Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. The patient’s verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.

  1. Answer: A. Restating a feeling or thought the patient has expressed.

Rationale: Restating allows the patient to validate the nurse’s understanding of what has been communicated. Restating is an active listening technique. Judgments should be suspended in a nurse-patient relationship. Close-ended questions such as “Did you feel angry?” ask for specific information rather than showing understanding. When the nurse simply states that he or she understands the patient’s words, the patient has no way of measuring the understanding.

  1. Answer: D. The nurse should have assessed the patient’s culture before making this diagnosis and plan.

Rationale: The amount of eye contact a person engages in is often culturally determined. In some cultures, eye contact is considered insolent, whereas in others eye contact is expected. Asian Americans, including persons from the Philippines, often prefer not to engage in direct eye contact.

  1. Answer: C. Silence can provide meaningful moments for reflection.

Answer: Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. A nurse breaking silences is not a principle related to silences. It is inaccurate to say that patients withdraw during long silences or that silence helps patients know that they are understood. Feedback helps patients know they have been understood.

  1. Answer: B, C, D

Rationale: Reflecting (“I can see that you feel sad,” “This is very painful for you”) and giving information (“Crying is a way of expressing hurt”) are therapeutic techniques. “Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

  1. Answer: A. “I will not share information with your family or friends without your permission, but I share information about you with other staff.”

Rationale: A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question.

  1. Answer: C. “I’m glad I could help you, but I can’t accept the gift. My reward is seeing you with a renewed sense of hope.”

Answer: Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient’s gesture of appreciation, but the gift should not be accepted. See relationship to audience response question.

  1. Answer: B. staying with a tearful patient.

Rationale: Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse’s ability to be therapeutic.

  1. Answer: D. Differing values are reflected in the two statements.

Rationale: Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others.

  1. Answer: A. Recognize the effectiveness of the relationship and patient’s thoughtfulness. Accept the card.

Rationale: The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient’s expression of gratitude. See relationship to audience response question.

  1. Answer: C. “That’s a good topic for you to discuss with your doctor.”

Rationale: Nurses should encourage patients to work at their optimal level of functioning. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency.

  1. Answer: A. boundary blurring

Rationale: When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming over-involved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.

  1. Answer: A, E

Rationale: The nurse needs support to explore these feelings. An experienced psychiatric nurse is a resource that may be helpful. The knowledge and experience gained from the nurse’s relationship with a mentally ill parent may contribute sensitivity to compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories.

  1. Answer: C. Arrange a temporary place for the patient to stay until new housing can be arranged.

Rationale: The case manager should intervene by arranging temporary shelter for the patient until an apartment can be found. This activity is part of the coordination and delivery of services that falls under the case manager role. None of the other options is a viable alternative.

  1. Answer: C. explain that the patient will continue to improve if the medication is taken regularly.

Rationale: Patients do not stay in a hospital until every symptom disappears. The nurse must assume responsibility to advocate for the patient’s right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Security is unnecessary. The nurse can handle this matter.

  1. Answer: C. Assess the patient’s weight; determine foods and amounts eaten.

Rationale: Assessment of biopsychosocial needs and general ability to live in the community is called for before any other action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. The rule is to assess before taking action. Hospitalization may not be necessary. Smoking cessation strategies can be pursued later.

  1. Answer: C. “Can you identify what was happening when your anxiety began to increase?”

            Rationale: Assessing the trigger to the patient’s anxiety would help the nurse in planning care. This would also allow the nurse to determine which factors in the environment that she can modify to help the patient relax and focus on recovery. Options A, B and D are close-ended questions and would not allow the nurse to explore the patient’s feelings.

  1. Answer: “My focus is learning how to live my life.”

Rationale: This statement indicates that the patient is working his way to move forward from the loss and change his adapting patterns related to it. Expressing his focus on living his life indicates that while he acknowledges his loss, the patient realizes that he has a life to live. The rest of the options are incorrect.

  1. Answer: “I know this is difficult. tell me more about what you are feeling now.”

Rationale: This is a therapeutic communication technique. This response acknowledges the patient’s feelings and allows the patient to express feelings (and elaborate). This is an open ended question, promoting discussion and further therapeutic communication.

  1. Answer: “You’re concerned that it might happen to you?”

Answer: This response reflects the clients feelings. The therapeutic communication technique of repetition to clarify is used  by the nurse to allows the patient to express what he feels and helps the nurse to guide the patient to acknowledge his feelings. The rest of the options do not recognize the feelings of the patient and also tends to shift the focus from him to the nurse and/or other members of the health care team.

  1. Answer: A. “I know it is frightening. Tell me what is it about the swab test that frightens you?”

            Rationale: Acknowledging the patient’s feelings and allowing him to express his feelings help the nurse determine what triggers panic attacks and how she can help the patient resolve feelings of anxiety and provide him with useful information related to the swab testing. Options B and C did not recognize the feelings of the patient while in Option D, the nurse makes a suggestion which is not therapeutic.


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Nhiña Sandeep de Rosas, MAN, DIH, DSHRM, RN currently works for the Department of Health CHD Mimaropa as a Training Specialist. She is also a Nurse Licensure Exam and NCLEX-RN reviewer on her free time. She has her USRN licenses in New York and Vermont, having passed the NCLEX-RN in 2007.Since 2006, she has been a nurse educator and worked as a clinical instructor and classroom lecturer for Unciano Colleges (College of Nursing) in Antipolo City. She has earned her Master’s Degree in Nursing and Diploma in International Health at the University of the Philippines Open University; and her Diploma in Strategic Human Resource Management at the Ateneo de Manila University.


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