An individual was killed during a store robbery 2 weeks ago. The widowed spouse, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about the death. Which is the nurses most therapeutic comment?

Correct Answer: B

Rationale: The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for dysfunctional grieving because of the history of a severe psychiatric illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings. The patients crying 2 weeks after the spouses death is expected and normal.

Correct Answer: B

Rationale: Caregiver role strain refers to a caregivers felt or exhibited difficulty in performing a family caregiver role. In this case, one parent exhibits stress-related illness and the other exhibits increased anxiety. The other nursing diagnoses are not substantiated by the information given and are incorrectly formatted [one nursing diagnosis should not be the etiology for another].

Correct Answer: D

Rationale: A double-bind communication is one that is inherently contradictory, that is, a comment that gives conflicting directions. In this case, the wife on crutches suggests that her husband should go bowling but then indicates that she will be at greater risk if he does, which in effect tells him go ahead and dont do it at the same time. This remark places the husband in a double bind, a situation in which no acceptable response exists. The distracters are clear, direct communications.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.