Module 4 Exam Hesi compass Study Set
Questions With 100% Solved Solutions.
A schizophrenic client says, "I'm away for the day ... but don't think we should play ... or do we
have feet of clay?" Which alteration in the client's speech does the nurse document? - Answer
Clang association
A client with schizophrenia and his parents are meeting with the nurse. One of the young man's
parents says to the nurse, "We were stunned when we learned that our son had schizophrenia.
He was no different than from his older brother when they were growing up. Now he's had
another relapse, and we can't understand why he stopped his medication." Which response by
the nurse is appropriate? - Answer Cclient, "How can we help you to take your medicine or to
tell us when you're having problems so that your medication can be adjusted?"
An acutely ill schizophrenic client says to the nurse, "He keeps saying that he likes you, and I
keep telling him you're married, but he won't listen, and I think he's going to get fresh with
you." Once the nurse has determined that the client is hallucinating, which response to the
client would be most appropriate statement? - Answer A "Try not to listen to the voices right
now so that I can talk with you."
Rationale: The appropriate statement by the nurse is the one that does not acknowledge the
client's hallucinations. By responding, "I think that you can help him stop his behavior if you
concentrate" or "Tell him I said to mind his p's and q's or I'll call the police on him," the nurse
acknowledges the hallucinations. The nurse attempts to interpret the client's thinking with a
statement such as "I think that you're trying to share your own feelings toward me, but you're
shy."
A client says to the nurse, "It's over for me — the whole thing is over." Which response by the
nurse would be therapeutic? - Answer "Let's talk more about your feeling that the whole thing
is over for you. This is important, and I may need to share your feelings with other staff
members."
Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the
client that the nurse needs to share any information that requires crisis intervention with other
staff members. Asking, "What do you mean, 'The whole thing is over'?" employs paraphrasing,
but the message is blunt and closed-ended. In stating, "Over? Well, that sounds pretty drastic to
me. Let's discuss this in the strictest confidence," the nurse uses hysterical exaggeration (at an
inappropriate time) and gives incorrect information regarding confidentiality. In stating, "Can
you tell me more about why it's over for you? I'll keep your thoughts strictly confidential," the
,A nurse performing a lethality assessment asks the client whether he is thinking of suicide.
Which statement by the client would be of most concern to the nurse? - Answer "No, I wasn't,
but I am now, thanks to you."
Rationale: The client's response that he is now thinking about suicide is of the greatest concern
to the nurse. In making the statement "I hadn't thought of that, but I can see that you are" the
client projects his own thoughts of suicide onto the nurse. In stating, "Of course not, but there
are days when I think that I should be," the client is being sarcastic but is not specifically talking
about suicide. In stating, "What is suicide going to do for me except get me excommunicated
from the church?" the client indicates that suicide is not an option because of his religious
beliefs.
A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several
documents in an effort to organize them, "Well, I'm feeling so much better now since I got
organized. My lawyer wrote my will and durable power of attorney." Which response by the
nurse is appropriate? - Answer "You talk about getting organized. Are you thinking of killing
yourself?"
Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly
"feeling so much better" and putting affairs in order are key verbal and behavioral clues that the
client is planning to commit suicide. In exclaiming, "Good grief! You don't look organized to me,"
the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client's feelings.
In asking, "Okay, what are you up to today? Your behavior is not appropriate," the nurse uses
teasing to determine the client's behaviors, which minimizes them. Additionally, the nurse is
employing a nontherapeutic technique of judging. In stating, "If you keep behaving like this, you
know that I'll have to tell the doctor and we'll have to seclude you," the nurse uses a threat.
An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad
told me he had to marry Mom because she got pregnant." Which response by the nurse would
be therapeutic? - Answer "You're feeling that your folks didn't want you, but they chose to
marry and have you."
Rationale: In the correct option, the nurse uses reflection to explore the client's lethality risk
and then uses reframing to determine whether the client is able to view what happened in a
different way. In suggesting, "You feel that you were a burden and not wanted? Let's talk with
your parents to see whether you're right," the nurse uses paraphrasing but is then
nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, "Let's speak
with your parents about what you've just told me. Let's ask whether you were truly unwanted,"
the nurse uses a parental approach, which may be threatening to the client, who seems to have
been unable to talk with the parents before now. In stating, "Sounds like your father was very
inappropriate, but I'm certain that he didn't mean that you were a burden to him," the nurse
, my life." Which response by the nurse is therapeutic? - Answer "You seem to be saying that
your choices are final and that you've lost any other opportunities."
Rationale: The client in this question is engaging in catastrophizing rather than reframing and
viewing other alternatives. The task for the nurse is to assess the lethality of the client's
situation and to help the client feel empowered to take another course of action and find the
perseverance and confidence to do so. The therapeutic response here is the one that is
nonjudgmental. In responding, "What are you saying? Sounds like you need to pull yourself
together and go back to school," or "Sounds like you feel that things should come easy for you,
unlike the rest of us, who work for what we get," the nurse communicates with the client as a
parent, using a judging style. In stating, "Having faith in yourself is one thing, but looking at your
options realistically is another," the nurse communicates prematurely and gives advice.
A client who has twice attempted suicide says, "If people would just leave me alone and let me
do what I want with my life, I could get on with what I want to do." Which response should the
nurse should give to the client? - Answer "You've tried to end your life twice, yet you feel that
everyone should let you do what you want to do?"
Rationale: The therapeutic response is the one that offers reflection, which permits the client to
observe the content of what she is saying. In stating, "Of course, you can't be left alone to get
on with what you want to do," the nurse makes a response that is social and belittles the client's
feelings. In stating, "Okay, go ahead and do whatever you want to do. Human beings have free
will," the nurse makes a response that seems sarcastic and angry; it is also judgmental and
biased. In stating, "Sounds like you're angry with people for caring enough about you to try to
keep you from hurting yourself," the nurse makes a premature judgment.
A homeless client with an antisocial disorder is brought to the emergency department by the
police after disturbing customers in a department store. The client says to the nurse, "I need to
be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital,
I'll jump off a bridge." Which nursing intervention would be therapeutic? - Answer Sending the
client to a shelter that will provide temporary housing if he signs a contract agreeing not to
attempt suicide
Rationale: The client is clearly using suicide as a threat so that he will be hospitalized. As long as
self-harm is not an issue, providing the client with shelter will meet his needs. Sending the client
to the psychiatric hospital intake center immediately for evaluation is an intervention that
should be used if the client refuses to sign a contract for "no suicide." Guaranteeing the client a
hospital bed if he shows up for a follow-up appointment is manipulation, which is a
nontherapeutic intervention. The nurse would not order the police to arrest a client.
Questions With 100% Solved Solutions.
A schizophrenic client says, "I'm away for the day ... but don't think we should play ... or do we
have feet of clay?" Which alteration in the client's speech does the nurse document? - Answer
Clang association
A client with schizophrenia and his parents are meeting with the nurse. One of the young man's
parents says to the nurse, "We were stunned when we learned that our son had schizophrenia.
He was no different than from his older brother when they were growing up. Now he's had
another relapse, and we can't understand why he stopped his medication." Which response by
the nurse is appropriate? - Answer Cclient, "How can we help you to take your medicine or to
tell us when you're having problems so that your medication can be adjusted?"
An acutely ill schizophrenic client says to the nurse, "He keeps saying that he likes you, and I
keep telling him you're married, but he won't listen, and I think he's going to get fresh with
you." Once the nurse has determined that the client is hallucinating, which response to the
client would be most appropriate statement? - Answer A "Try not to listen to the voices right
now so that I can talk with you."
Rationale: The appropriate statement by the nurse is the one that does not acknowledge the
client's hallucinations. By responding, "I think that you can help him stop his behavior if you
concentrate" or "Tell him I said to mind his p's and q's or I'll call the police on him," the nurse
acknowledges the hallucinations. The nurse attempts to interpret the client's thinking with a
statement such as "I think that you're trying to share your own feelings toward me, but you're
shy."
A client says to the nurse, "It's over for me — the whole thing is over." Which response by the
nurse would be therapeutic? - Answer "Let's talk more about your feeling that the whole thing
is over for you. This is important, and I may need to share your feelings with other staff
members."
Rationale: The therapeutic response seeks clarification, employs paraphrasing, and informs the
client that the nurse needs to share any information that requires crisis intervention with other
staff members. Asking, "What do you mean, 'The whole thing is over'?" employs paraphrasing,
but the message is blunt and closed-ended. In stating, "Over? Well, that sounds pretty drastic to
me. Let's discuss this in the strictest confidence," the nurse uses hysterical exaggeration (at an
inappropriate time) and gives incorrect information regarding confidentiality. In stating, "Can
you tell me more about why it's over for you? I'll keep your thoughts strictly confidential," the
,A nurse performing a lethality assessment asks the client whether he is thinking of suicide.
Which statement by the client would be of most concern to the nurse? - Answer "No, I wasn't,
but I am now, thanks to you."
Rationale: The client's response that he is now thinking about suicide is of the greatest concern
to the nurse. In making the statement "I hadn't thought of that, but I can see that you are" the
client projects his own thoughts of suicide onto the nurse. In stating, "Of course not, but there
are days when I think that I should be," the client is being sarcastic but is not specifically talking
about suicide. In stating, "What is suicide going to do for me except get me excommunicated
from the church?" the client indicates that suicide is not an option because of his religious
beliefs.
A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several
documents in an effort to organize them, "Well, I'm feeling so much better now since I got
organized. My lawyer wrote my will and durable power of attorney." Which response by the
nurse is appropriate? - Answer "You talk about getting organized. Are you thinking of killing
yourself?"
Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly
"feeling so much better" and putting affairs in order are key verbal and behavioral clues that the
client is planning to commit suicide. In exclaiming, "Good grief! You don't look organized to me,"
the nurse nontherapeutically uses hysterical exaggeration, which minimizes the client's feelings.
In asking, "Okay, what are you up to today? Your behavior is not appropriate," the nurse uses
teasing to determine the client's behaviors, which minimizes them. Additionally, the nurse is
employing a nontherapeutic technique of judging. In stating, "If you keep behaving like this, you
know that I'll have to tell the doctor and we'll have to seclude you," the nurse uses a threat.
An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad
told me he had to marry Mom because she got pregnant." Which response by the nurse would
be therapeutic? - Answer "You're feeling that your folks didn't want you, but they chose to
marry and have you."
Rationale: In the correct option, the nurse uses reflection to explore the client's lethality risk
and then uses reframing to determine whether the client is able to view what happened in a
different way. In suggesting, "You feel that you were a burden and not wanted? Let's talk with
your parents to see whether you're right," the nurse uses paraphrasing but is then
nontherapeutic in trying to persuade the client to talk to the parents. In suggesting, "Let's speak
with your parents about what you've just told me. Let's ask whether you were truly unwanted,"
the nurse uses a parental approach, which may be threatening to the client, who seems to have
been unable to talk with the parents before now. In stating, "Sounds like your father was very
inappropriate, but I'm certain that he didn't mean that you were a burden to him," the nurse
, my life." Which response by the nurse is therapeutic? - Answer "You seem to be saying that
your choices are final and that you've lost any other opportunities."
Rationale: The client in this question is engaging in catastrophizing rather than reframing and
viewing other alternatives. The task for the nurse is to assess the lethality of the client's
situation and to help the client feel empowered to take another course of action and find the
perseverance and confidence to do so. The therapeutic response here is the one that is
nonjudgmental. In responding, "What are you saying? Sounds like you need to pull yourself
together and go back to school," or "Sounds like you feel that things should come easy for you,
unlike the rest of us, who work for what we get," the nurse communicates with the client as a
parent, using a judging style. In stating, "Having faith in yourself is one thing, but looking at your
options realistically is another," the nurse communicates prematurely and gives advice.
A client who has twice attempted suicide says, "If people would just leave me alone and let me
do what I want with my life, I could get on with what I want to do." Which response should the
nurse should give to the client? - Answer "You've tried to end your life twice, yet you feel that
everyone should let you do what you want to do?"
Rationale: The therapeutic response is the one that offers reflection, which permits the client to
observe the content of what she is saying. In stating, "Of course, you can't be left alone to get
on with what you want to do," the nurse makes a response that is social and belittles the client's
feelings. In stating, "Okay, go ahead and do whatever you want to do. Human beings have free
will," the nurse makes a response that seems sarcastic and angry; it is also judgmental and
biased. In stating, "Sounds like you're angry with people for caring enough about you to try to
keep you from hurting yourself," the nurse makes a premature judgment.
A homeless client with an antisocial disorder is brought to the emergency department by the
police after disturbing customers in a department store. The client says to the nurse, "I need to
be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital,
I'll jump off a bridge." Which nursing intervention would be therapeutic? - Answer Sending the
client to a shelter that will provide temporary housing if he signs a contract agreeing not to
attempt suicide
Rationale: The client is clearly using suicide as a threat so that he will be hospitalized. As long as
self-harm is not an issue, providing the client with shelter will meet his needs. Sending the client
to the psychiatric hospital intake center immediately for evaluation is an intervention that
should be used if the client refuses to sign a contract for "no suicide." Guaranteeing the client a
hospital bed if he shows up for a follow-up appointment is manipulation, which is a
nontherapeutic intervention. The nurse would not order the police to arrest a client.
