A client tells the nurse that his wife’s nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon.Which of the following responses is the most therapeutic for the client?
Answer(s): C
The client needs to learn how to communicate directly with his wife about her behavior. The nurse’s assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation.Choices “Tell me more specifically about her complaints.” and “Can you think why she might nag you so much?” inappropriately direct attention away from the client and toward his wife, who isn’t present.Choice “Why do you want me to initiate this in tomorrow’s session rather than you?” implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client.Instead of focusing on his problems, he’ll waste precious time convincing the nurse that he or she should do his work.
During the work phase of the nurse-client relationship, the client says to her primary nurse, “You think that I could walk if I wanted to, don’t you?”What is the best response by the nurse?
Answer(s): D
This response answers the question honestly and nonjudgmentally and helps to preserve the client’s self- esteem.Choice “Yes, if you really wanted to, you could.” is an open and candid response but diminishes the client’s self- esteem.Choice “Tell me why you’re concerned about what I think.” doesn’t answer the client’s and is not helpful.Choice “Do you think you could walk if you wanted to?” increases the client’s anxiety because her inability to walk might be directly related to an unconscious psychological conflict that has not been resolved.
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic self-expectations) is when the client can ______________.
Answer(s): A
The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept.When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is ______________.
If there are indications of a body image disturbance, the nursing care plan should include body disturbances, related to a functional or physical problem.The disturbance might be an anticipated one – that is, weight gain and pregnancy.Stressors can include a change in physical appearance, sexuality concerns, or an unrealistic ideal self.
After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
Victims of domestic violence are often correct at predicting their risk of harm. However, the nurse should ensure that the client is expressing herself authentically and is not trying to convince the nurse that there is no immediate danger. Further, proper authorities, such as the police, should be alerted to this reportable offense.
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