Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39)

Module 4 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 1 1 / 1 pts A client with schizophrenia 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? Neologism Word salad Correct! Clang association Associative looseness Rationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words. A neologism is a made-up word that has meaning only to the client. Word salad is the term for a mixture of meaningless phrases, either to the client or to the listener. Associative looseness is a term used to describe schizophrenic speech in which connections and threads are interrupted or missing. Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client with schizophrenia is needed to answer this question. Focus on the data in the question and note the meaningless rhyming of words. Review these speech patterns with schizophrenia if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 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? Telling the parents, “Medication noncompliance is the most frequent reason that people with this diagnosis relapse.” Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” Correct! Asking the client, “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?” Saying to the parents, “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.” Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client’s behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live with you if he stops the medication.” The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating “Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication,” the nurse gives approval and prematurely analyzes the client’s motivation without sufficient assessment. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. Also note that the correct option is the only option in which the nurse directly addresses the client. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health hallucinating, which response to the client would be most appropriate statement? Correct! “Try not to listen to the voices right now so that I can talk with you.” “I think that you can help him stop his behavior if you concentrate.” “Tell him I said to mind his p’s and q’s or I’ll call the police on him.” “I think that you’re trying to share your own feelings toward me, but you’re shy.” 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.” Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember that the nurse should not acknowledge the client’s hallucinations. Also note that the correct option is the only one that encourages realistic verbalization from the client. Review therapeutic communication techniques with a client who is hallucinating if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 4 0 / 1 pts A client says to the nurse, “It’s over for me—the whole thing is over.” Which response by the nurse would be therapeutic? You Answered “What do you mean, ‘The whole thing is over’?” “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictest confidence.” “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictly confidential.” Correct 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 nurse uses the therapeutic technique of seeking clarification but does not clarify with the client that the information might need to be shared. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that shared information will be maintained as confidential. To select from the remaining options, focus on the statement that addresses the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health “What is suicide going to do for me except get me excommunicated from the church?” 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. Test-Taking Strategy: Use the process of elimination and note the strategic words “of most concern to the nurse.” Note the words “but I am now” in the correct option. This is the only option that identifies definite suicidal thoughts. Review lethality assessment in the suicidal client if you had difficulty with this question. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Mental Health “Okay, what are you up to today? Your behavior is not appropriate.” Correct! “You talk about getting organized. Are you thinking of killing yourself?” “If you keep behaving like this, you know that I’ll have to tell the doctor, and we’ll have to seclude you.” 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. Test-Taking Strategy: Use the process of elimination. Focus on the information in the question and note the relationship between the words “expressed suicidal ideation” in the question and “thinking of killing yourself” in the correct option. Review the clues that indicate the potential for suicide if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health 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? Correct! “You’re feeling that your folks didn’t want you, but they chose to marry and have you.” “You feel that you were a burden and not wanted? Let’s talk with your parents to see whether you’re right.” “Let’s speak with your parents about what you’ve just told me. Let’s ask whether you were truly unwanted.” “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean that you were a burden to him.” 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 offers an opinion about the client’s father and then provides false reassurance. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that address discussing the client’s feelings with the parents. In selecting from the remaining options, remember to focus on the client’s feelings. Select the option that exemplifies therapeutic communication technique. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health “Having faith in yourself is one thing, but looking at your alternatives realistically is another.” Correct! “You seem to be saying that your choices are final and that you’ve lost any other opportunities.” “Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get.” 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 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. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that demonstrate the nurse using a judging style to deal with the client. To select from the remaining options, eliminate the option that is nontherapeutic in that the nurse gives advice. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 9 1 / 1 pts 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? “Of course you can’t be left alone to get on with what you want to do.” “Okay, go ahead and do whatever you want to do. Human beings have free will.” Correct! “You’ve tried to end your life twice, yet you feel that everyone should let you do what you want to do?” “Sounds like you’re angry with people for caring enough about you to try to keep you from hurting yourself.” 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. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only response that is therapeutic in that it uses reflection. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Mental Health