Question 1

A patient says, "I went out drinking only one time last week.At least I'm trying to change." The nurse responds, "I appreciate your effort, but you agreed to abstain from alcohol completely." The nurse's response demonstrates the ability to manage what potential patient centered problem?

Accepted Answer

The nurse's response addresses manipulation, as the patient attempts to minimize or justify their behavior (going out drinking despite an agreement to abstain) by highlighting a perceived effort to change. The nurse counters this by reminding the patient of their commitment, thus managing the patient's attempt to manipulate the situation or the agreement made regarding their health behavior.

Question 2

A nurse and patient agree on problems to be addressed during a brief hospital stay.Which interpretation of this action is correct?

Accepted Answer

The agreement on problems to be addressed indicates that the nurse and patient have established a therapeutic relationship and are moving into the working stage, where they will begin to address and work on the identified problems. Reinforcing messages about termination (B) may be important later on in the relationship, but it is not the immediate interpretation of this action. Similarly, directing the patient to begin journaling (C) or ensuring management of emotions (D) may be beneficial for the therapeutic process, but it is not the immediate interpretation of the agreement on problems.

Question 3

A patient is withdrawn and avoids talking to the nurse.The nurse should identify which action is the initial intervention for this patient?

Accepted Answer

The initial intervention for a withdrawn patient is to extend a respectful offer to listen and help. This shows the patient that the nurse is willing to engage and opens the door to communication. Directly asking why the patient does not wish to talk can be perceived as confrontational and may cause the patient to withdraw further. Involving the patient in a group activity or respecting their desire not to talk by leaving them alone may not address the underlying issue causing the patient's withdrawal.

Question 4

What statement made by a nursing is most helpful when moving into the working stage of a therapeutic relationship with a patient?

Accepted Answer

Option C is most helpful for moving into the working stage of a therapeutic relationship because it involves the patient in the decision-making process about their care, encouraging them to take an active role in identifying and prioritizing their problems to work on. This approach fosters collaboration and empowers the patient.

Question 5

Which goal statement is most appropriate for a newly admitted patient currently in the orientation stage of the nurse-patient relationship?

Accepted Answer

During the orientation stage, it is important to establish trust and rapport with the patient. Option C is the most appropriate goal statement for this stage. The other options focus more on specific outcomes related to the patient's abilities, which may be more appropriate for later stages of the nurse-patient relationship.

Question 6

A patient diagnosed with schizophrenia says to the nurse, "I feel really close to you.You're the only true friend I have." What is the nurse's most therapeutic response?

Accepted Answer

The response acknowledges the professional nature of the relationship while also addressing the patient's need for personal connections, encouraging exploration of personal friendships.

Question 7

A nurse and patient who developed a therapeutic relationship enter into the final phase of their relationship as the patient prepares for discharge.What is an important nursing intervention for this stage of the relationship?

Accepted Answer

The answer of A nurse and patient who developed a...

Question 8

A newly admitted patient tells the nurse, "The voices are bothering me." What should be the nurse's initial intervention?

Accepted Answer

Seeking a description of the voices to identify themes would be the best initial intervention. This would allow the nurse to gather more information about the patient's hallucinations and understand the patient's experience better. It can also assist the healthcare provider in creating an appropriate treatment plan for the patient. Ignoring the patient's reference to voices can lead to the patient feeling invalidated, and distracting the patient may not resolve the underlying issue. Telling the patient that the voices do not exist will not help the patient and can increase their stress levels.

Question 9

A novice nurse says, "I have more important things to do than play games with patients.These activities are not a worthwhile use of my time." What is the nurse manager's most helpful response?

Accepted Answer

Informal activities such as games help patients develop social skills by providing opportunities to interact with others in a non-threatening environment. Playing games can also encourage patients to take risks, which can be helpful in the overall therapeutic process. As a nurse, it is important to recognize the value of these activities and incorporate them into the patient experience.

Question 10

Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship?

Accepted Answer

Choice C indicates that the patient is recognizing the need for help and is willing to work with the nurse to resolve their issues. The other choices suggest either blind obedience or reluctance, neither of which promote collaboration in the nurse-patient relationship.

Question 11

A patient playing pool with another patient throws down the pool cue and begins swearing.What action should the nurse implement initially to address this situation?

Accepted Answer

Suggesting a time-out in the patient's room is the best initial action as it allows the patient to calm down in a safe environment while also removing them from the triggering situation. This also allows the staff to assess the situation and determine if any further interventions are necessary.

Question 12

Which statement is most therapeutic when working with a patient believed to be experiencing emotional pain?

Accepted Answer

Option A acknowledges the patient's pain and expresses a desire to help, while also avoiding making assumptions about the severity or cause of the pain. This statement is empathetic and offers support, which is typically more helpful to patients than sympathy (option B) or making promises to solve the problem (option C). Option D is dismissive and invalidating, which can be harmful to the therapeutic relationship.

Question 13

Which nursing intervention will initially be most helpful for trust building with a suspicious patient?

Accepted Answer

Keeping appointments and promises is a consistent behavior that builds trust with patients. This contributes to a therapeutic relationship, which is key to successful nursing care. Enforcing rules may cause mistrust or pushback from the patient, while agreeing not to document disclosures or openly challenging unclear statements may compromise patient safety and care.

Question 14

A nurse tells a patient, "I know how you feel.My spouse can be very insensitive too.I am also considering divorce." What behavior is the nurse demonstrating?

Accepted Answer

The nurse is demonstrating inappropriate self-disclosing by sharing personal information that is not relevant or helpful to the patient's situation. It can also be seen as unprofessional as the focus should be on the patient and their needs, not the nurse's personal life.

Question 15

An inpatient says, "Last time I was here, a primary nurse talked with me every day.This time, different nurses work with me.How can I make progress?" Which nursing response best addresses the patient's concern?

Accepted Answer

This response acknowledges the patient's concern and provides information about how different nurses work together to help patients progress. It also emphasizes the importance of shift reports, care plans, and progress notes in ensuring continuity of care.

Question 16

Which patient behavior would require the most immediate limit-setting by the nurse?

Accepted Answer

Verbal abuse and accusations of sexual misconduct are serious boundary violations that require immediate intervention to protect the safety and dignity of the roommate. It is important for the nurse to respond calmly and assertively, and to communicate clear limits around acceptable behavior.

Question 17

A patient shouts at a nurse who just entered the room, "You're an incompetent fool.Leave me alone." The nurse's response should be based on which rationale?

Accepted Answer

The anger is likely displaced from another situation or person, not the nurse, so understanding this can help the nurse respond appropriately.

Question 18

A patient has identified the need for better anger management and tells the nurse, "I'm afraid that someday I might explode." What is the best strategy for reducing this patient's fear of losing control?

Accepted Answer

Talking about feelings openly and directly helps the patient confront and understand their emotions, which is crucial for effective anger management.

Question 19

A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem?

Accepted Answer

The initial step of the problem-solving process is to accurately describe the problem or situation. Only after understanding the problem can the nurse begin to consider alternative behaviors, determine necessary changes, and decide on a plan of action.

Question 20

A patient is hospitalized for severe depression.Knowing that the patient will be discharged after a short stay, what is the nurse's first priority?

Accepted Answer

Developing a goal-directed, problem-centered relationship is the nurse's first priority in this context. This approach helps in establishing clear objectives for the patient's care and recovery, focusing on addressing the patient's immediate needs and problems, which is crucial for a short-term hospital stay.

Quiz 9: Working With an Individual Patient