A patient says, 'I've done a lot of cheating and manipulating in my relationships.' Select a nonjudgmental response by the nurse.

Correct Answer: A

Rationale: In this scenario, the correct response is option A) "How do you feel about that?" This response is nonjudgmental, open-ended, and encourages the patient to explore their feelings without imposing any value judgments. As a nurse, it is crucial to create a safe and supportive environment for patients to express themselves honestly and openly. Option B) "I am glad that you realize this." is not the best response because it may come across as insincere or patronizing. It does not invite further exploration or reflection from the patient. Option C) "That's not a good way to behave." is judgmental and can make the patient feel defensive or ashamed, hindering effective communication and rapport-building. Option D) "Have you outgrown that type of behavior?" implies an expectation of change and may pressure the patient to provide a specific response. It does not acknowledge the complexity of the patient's experiences or emotions. In an educational context, this question highlights the importance of therapeutic communication in nursing practice. By choosing the right response, nurses can foster trust, encourage self-reflection, and support patients in their journey towards healing and personal growth. It underlines the significance of empathy, active listening, and nonjudgmental attitude in building therapeutic relationships with patients.

Correct Answer: B

Rationale: In this scenario, option B is the correct analysis of the nurse's behavior. The nurse's gesture of reaching out to take the patient's hand without understanding the patient's cultural background or individual preferences regarding touch could be premature and potentially misinterpreted. This action could be perceived as intrusive or crossing personal boundaries, especially in a sensitive and emotional situation like the death of a child. In behavioral nursing, it is crucial to respect the patient's autonomy and preferences, including their physical boundaries and comfort levels with touch. Option A is incorrect because while the nurse's intention may be to show empathy and compassion, the impact of the gesture can vary based on individual perceptions. Option C highlights the potential negative perception of the gesture, which aligns with the correct analysis. Option D is overly generalized and not applicable to this specific situation. In an educational context, this question emphasizes the importance of cultural competence, communication skills, and respecting boundaries in nursing practice, especially in emotional and delicate situations. Nurses must always consider individual preferences and cultural norms when providing care to ensure patient-centered and respectful interactions.

Correct Answer: B

Rationale: The most appropriate nursing response in this scenario is option B) "Tell me more about your role as president." This response is empathetic, non-confrontational, and demonstrates therapeutic communication techniques. By engaging the patient in discussing their delusion, the nurse shows respect for their feelings and experiences, which can help build rapport and trust. Option A) "That's not true. You are not the president." is confrontational and dismissive, which can escalate the patient's distress and hinder therapeutic communication. It does not acknowledge the patient's reality or emotions. Option C) "You need to focus on reality and stop believing the delusions." is directive and may cause the patient to feel judged or misunderstood. It does not address the underlying emotions or reasons behind the delusion. Option D) "You are not the president, but I understand that you are feeling very important." is partially acknowledging the patient's feelings but still corrects the delusion. However, it does not fully explore the patient's experience or engage in a therapeutic conversation. In behavioral nursing, it is crucial to approach patients with empathy, respect, and understanding. By using open-ended questions and active listening, nurses can help patients explore their thoughts and feelings, leading to more effective therapeutic interventions and outcomes.

Correct Answer: B

Rationale: The most appropriate response by the nurse is option B) "Let's talk about why you feel afraid to eat and how we can help." This response demonstrates therapeutic communication skills and empathy towards the patient's feelings. It acknowledges the patient's fear and opens the door for further exploration and support. Option A is incorrect because it dismisses the patient's fear and oversimplifies the issue, potentially causing the patient to feel misunderstood or invalidated. Option C is not the best response as it comes across as directive and may increase the patient's resistance. Option D, while true, lacks the empathetic approach needed when addressing psychological issues like eating disorders. In an educational context, it is crucial for healthcare providers to approach patients with eating disorders with sensitivity and understanding. By acknowledging the patient's feelings and offering support, nurses can build trust and create a safe space for patients to discuss their struggles and work towards recovery. Therapeutic communication is fundamental in nursing practice, especially when dealing with mental health issues like anorexia nervosa.

Correct Answer: A

Rationale: The correct answer is option A: Ensure the patient is in a safe environment and assess for suicidal thoughts. This is the priority nursing intervention because the patient's statement indicates a risk of harm to themselves. Ensuring the patient's safety is the immediate concern to prevent any self-inflicted harm. Assessing for suicidal thoughts is crucial to determine the severity of the situation and provide appropriate interventions. Option B, administering antipsychotic medication, is important in the long-term management of schizophrenia but is not the priority in this situation where the patient is at risk of self-harm. Option C, encouraging the patient to engage in reality-based activities, may not be effective when the patient is actively experiencing hallucinations. Option D, validating the patient's hallucinations and offering reassurance, does not address the immediate safety concern and may not be appropriate if the hallucinations are prompting self-harm. In an educational context, understanding the priority of interventions based on the patient's immediate needs is crucial in psychiatric nursing. Recognizing and responding to suicidal ideation or self-harm risks are fundamental skills for nurses caring for patients with mental health disorders like schizophrenia. This scenario highlights the importance of quick assessment and action to ensure patient safety in psychiatric emergencies.