Question

Terry a 25 years old male consistently avoided thoughts and images related to witnessing the injuries and deaths of others during an earthquake during a recent tourist trip to Syria. After his return to USA, he began spending more time at work and filling his days with hobbies and activities. However, whenever he had free time, he would have unwanted intrusive thoughts about the earthquake. In addition, he was having increasingly distressing nightmares. Which comment by the client requires the nurse to make a close ended question?

Answer 1

Correct Answers:

"I saw my best friend get killed by a falling building. It should have been me instead."

Rationale :

🔴 This statement reflects survivor guilt and may indicate suicidal ideation or self-blame, which are high-risk findings.

🔴 When client safety is a concern, the nurse must use close-ended questions to obtain clear, direct information.

🔴 Close-ended questions (yes/no or specific answers) help the nurse rapidly assess risk, such as intent or plans for self-harm.

🔴 This approach ensures immediate clarification rather than allowing vague or avoidant responses.

🔴 Early identification of suicidal thoughts allows the nurse to initiate appropriate safety interventions.

❌ Incorrect Options:

🔸 “It’s good to be home. I was waiting to be back. I missed my family and friends.”

This reflects relief and positive coping after trauma. An open-ended question would encourage emotional expression.

🔸 “I want to continue my education but I’m not sure how I will fit in with other college students.”

This indicates uncertainty and adjustment concerns, best explored with open-ended questions to understand feelings.

🔸 “Sometimes I think I hear the sound of buildings falling, but it’s just the noise of traffic in my hometown.”

This suggests re-experiencing symptoms of trauma, appropriate for open-ended exploration rather than immediate yes/no questioning.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

The client's verbal and nonverbal messages are incongruent.

Rationale :

🔷 Incongruent communication occurs when a client’s verbal message does not match nonverbal behaviors.

🔷 Marcus verbally states enjoyment of the interaction, yet his nonverbal cues—fidgeting, foot tapping, face covering, and scanning under the chair—suggest anxiety and distress.

🔷 Nurses assess both verbal and nonverbal communication to understand the client’s true emotional state.

🔷 Noting incongruence helps the nurse clarify feelings and respond therapeutically rather than taking words at face value.

🔷 Accurate interpretation supports effective assessment and rapport, especially in mental health settings.

❌ Incorrect Options:

🔸 The client is clearly demonstrating psychotic behaviors: Psychosis involves hallucinations, delusions, or disorganized thinking, which are not evident here. The behaviors described are consistent with anxiety, not psychosis.

🔸 The nurse is interpreting the client's behavior through a personal cultural filter: The documentation objectively describes observable behaviors without cultural assumptions. There is no evidence of bias influencing interpretation.

🔸 The client is giving positive feedback about the nurse's communication techniques: While the verbal statement is positive, the nonverbal behaviors contradict it, making this analysis incomplete.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

"Please explain what you mean by 'dreamed about the dark hour"

Rationale :

🔹 Clarification invites the client to define their own meaning using their own words.

🔹 Asking the client to explain a specific phrase prevents assumptions or misinterpretation.

🔹 This response keeps the focus on the client’s experience, not the nurse’s interpretation.

🔹 It promotes accurate assessment by gathering precise information.

🔹 Clarification is a core therapeutic communication technique used when language is vague or symbolic.

❌ Incorrect Options:

🔸 “I understand what you're saying. Bad dreams leave me feeling tired, too.” This introduces self-disclosure and assumes shared meaning, which blocks clarification.

🔸 “It sounds like you were uncomfortable with the content of your dream.” This is an interpretation, not clarification, and may be inaccurate.

🔸 “So, overall, you feel like you didn't sleep very well last night?” This is restating/summarizing, not clarifying the unclear phrase.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Working

Rationale :

🔹 The working phase is when the nurse and client actively address problems and implement plans.

🔹 Goal setting and behavior change strategies are central activities in this phase.

🔹 The client collaborates with the nurse to practice new behaviors and evaluate progress.

🔹 This phase involves problem-solving, teaching, and support.

🔹 Mutually agreed, measurable goals indicate the relationship has moved beyond orientation.

❌ Incorrect Options:

🔸 Preorientation: Occurs before meeting the client; no goals are set with the client.

🔸 Orientation: Focuses on establishing trust and identifying problems, not implementing goals.

🔸 Termination: Involves reviewing progress and ending the relationship, not initiating goals.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

The nurse's gesture is premature. The client's cultural and individual interpretation of touch is unknown.

Rationale :

🔹 Touch can be therapeutic, but it must be used cautiously, especially during an initial interview.

🔹 In early interactions, the nurse has not yet established trust or assessed the client’s comfort level with physical touch.

🔹 Cultural background, personal history, and trauma experiences strongly influence how touch is perceived and interpreted.

🔹 Even well-intended gestures may be misunderstood or experienced as intrusive if used too soon.

🔹 Therapeutic communication prioritizes emotional safety, which requires assessment before physical contact.

❌ Incorrect Options:

🔸 The action is inappropriate. Clients in a psychiatric setting should never be touched: This is incorrect because therapeutic touch can be appropriate when used thoughtfully and with consent.

🔸 It shows empathy and compassion and will encourage expression: While empathy is important, empathy does not require physical touch, especially before rapport is established.

🔸 Clients will always perceive the gesture as intrusive: Perception of touch is individualized, not universal. Some clients may find it comforting, others may not.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

The nurse should have assessed the client's culture before concluding the client had low self-esteem.

Rationale :

🔹 Eye contact is culturally influenced, and avoiding eye contact can be a sign of respect or modesty in many cultures, including some Filipino cultural norms.

🔹 The nurse made an incorrect assumption by interpreting behavior through a personal cultural lens rather than conducting a cultural assessment.

🔹 Cultural misunderstandings can lead to misdiagnosis and ineffective interventions.

🔹 Effective psychiatric nursing requires culturally competent care, recognizing that behaviors may have different meanings across cultures.

🔹 Assessing cultural background first supports accurate interpretation and individualized care planning.

❌ Incorrect Options:

🔸 The nurse should not have independently embarked on treatment planning: Nurses do participate in treatment planning, but it must be based on accurate assessment. The issue was not independence, but misinterpretation.

🔸 The client's poor eye contact indicates anger and hostility: There is no evidence of anger or hostility. This interpretation again reflects assumptive reasoning.

🔸 The client’s eye contact should have been directly addressed by role-playing: Role-playing without cultural understanding may be inappropriate and potentially disrespectful.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

"Tell me how your relationship was with your mother."

Rationale :

🔹 Empathy involves acknowledging the client’s feelings and experiences and inviting them to express emotions openly.

🔹 This response encourages the client to share personal meaning related to the loss without judgment or minimization.

🔹 It keeps the focus on the client’s perspective, not the nurse’s opinions or experiences.

🔹 Open-ended exploration of loss supports emotional processing and therapeutic rapport.

🔹 Empathetic communication validates grief and helps the client feel heard and understood.

❌ Incorrect Options:

🔸 “Losing a job isn’t always a bad thing.” This minimizes the client’s loss and can feel dismissive of her emotional pain.

🔸 “Let’s not focus on what’s sad but rather what is good about life.” This blocks emotional expression and discourages healthy grieving.

🔸 “I lost my parents last year and still feel sad.” This is self-disclosure, which shifts focus away from the client and is not therapeutic at this moment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

It looks like you're frightened, but I will stay here with you and keep you safe.

Rationale :

🔹 This response acknowledges the client’s emotional state (fear) without validating or reinforcing hallucinations.

🔹 It provides reassurance and presence, which helps reduce anxiety and agitation in clients with altered mental status.

🔹 The nurse avoids arguing about the reality of the perceptions while maintaining client safety and trust.

🔹 Staying with the client demonstrates empathy and support, core elements of therapeutic communication.

🔹 This approach helps ground the client in reality and promotes calm during distressing experiences.

❌ Incorrect Options:

🔸 “You should not be seeing things. There’s nothing there.” This dismisses the client’s experience and can increase fear or mistrust.

🔸 “Please tell me about what you are seeing, you are not right.” While asking about perceptions can be appropriate, the phrasing is judgmental and nontherapeutic.

🔸 “If you take your medications exactly as prescribed, this confusion will stop.” This is premature reassurance and shifts focus away from immediate emotional support.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

"Please tell me about how you feel about other kids treating you like that."

Rationale :

🔹 This response uses an open-ended question that invites the child to express feelings in their own words.

🔹 It validates the child’s experience without minimizing or judging what is happening.

🔹 Encouraging expression helps the nurse assess the emotional impact of peer rejection and bullying.

🔹 The focus remains client-centered, allowing the child to feel heard and supported.

🔹 This approach builds trust and rapport, which is essential for effective school nursing interventions.

❌ Incorrect Options:

🔸 “That happens to many kids at your age. Just ignore them…” This minimizes the child’s feelings and offers advice prematurely, which can shut down communication.

🔸 “If they do that, they do not deserve your friendship…” This is judgmental and directive, shifting focus away from the child’s emotions.

🔸 “You must be strong. Do the same to them…” This promotes retaliation, which is unsafe and nontherapeutic.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

"It sounds like you're worried about your privacy. Please tell me about your concerns?"

Rationale :

🔹 This response acknowledges the client’s feelings (fear/anxiety) without agreeing with or reinforcing the delusion.

🔹 It keeps the nurse reality-based while allowing the client to express concerns safely.

🔹 Open-ended, nonjudgmental language supports rapport and trust, essential in schizophrenia care.

🔹 By focusing on emotions rather than the belief, the nurse avoids arguing or validating false ideas.

🔹 This approach helps reduce anxiety and maintains a therapeutic alliance.

❌ Incorrect Options:

🔸 “You will be fine… you’re safe here.” This argues with the delusion and may increase defensiveness or mistrust.

🔸 “You have lost touch with reality…” This is confrontational and labeling, which can damage rapport.

🔸 “Let’s talk about something other than the FBI… tell me how you might see the cameras…” This shifts focus but still explores the delusion, risking reinforcement.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

3 :
A client says to the nurse, I dreamed about the dark hour. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which nursing response would be most appropriate if the nurse wants to seek clarification?

5 :
During the first interview with a young mother whose child died recently in a car accident, her female nurse feels touched by client's situation and reaches out to take the client's hand. Select the correct analysis of the nurse's behavior.

9 :
A school-age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response.

10 :
A client diagnosed with schizophrenia approaches the nurse and says, "The FBI is monitoring us through cameras and microphones in this room Be careful what you say." The client appears tense and frequently glances at the ceiling corners. Which is the best response by the nurse?

QLexNursing

3 : A client says to the nurse, I dreamed about the dark hour. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which nursing response would be most appropriate if the nurse wants to seek clarification?

5 : During the first interview with a young mother whose child died recently in a car accident, her female nurse feels touched by client's situation and reaches out to take the client's hand. Select the correct analysis of the nurse's behavior.

9 : A school-age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response.

10 : A client diagnosed with schizophrenia approaches the nurse and says, "The FBI is monitoring us through cameras and microphones in this room Be careful what you say." The client appears tense and frequently glances at the ceiling corners. Which is the best response by the nurse?

3 :
A client says to the nurse, I dreamed about the dark hour. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which nursing response would be most appropriate if the nurse wants to seek clarification?

5 :
During the first interview with a young mother whose child died recently in a car accident, her female nurse feels touched by client's situation and reaches out to take the client's hand. Select the correct analysis of the nurse's behavior.

9 :
A school-age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response.

10 :
A client diagnosed with schizophrenia approaches the nurse and says, "The FBI is monitoring us through cameras and microphones in this room Be careful what you say." The client appears tense and frequently glances at the ceiling corners. Which is the best response by the nurse?