ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
The nurse initiating a therapeutic relationship with a client should explain the purpose, which is to
Correct Answer: D
Rationale: The client who has unmet or unsatisfactorily met needs seeks to make changes; the nurse facilitates this desire to change. The focus of the therapeutic relationship is on the client's needs, not the nurse's. The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the client's problems; and clarifies expectations.
Question 2 of 5
During a regular home health visit to an elderly client, the nurse observes that the client has feelings of hopelessness and despair. The client says, 'I'm old, and my life has no purpose anymore. But promise me you won't tell anyone.' How should the nurse respond?
Correct Answer: B
Rationale: The correct answer is B) "I'm sorry, but I can't keep that kind of secret." This response is appropriate because the client's statement of feeling hopeless and having no purpose raises concerns about their mental health and well-being, and it is essential to address these issues promptly. As a nurse, it is crucial to prioritize the client's safety and seek help when necessary. Keeping such a serious concern confidential could put the client at risk. Option A) "Don't worry, I won't tell anyone else" is incorrect as it fails to address the client's underlying issues and might compromise the client's safety by not seeking appropriate support. Option C) "Let's talk about something to cheer you up" is inappropriate as it dismisses the client's feelings and fails to address the seriousness of the situation. Option D) "What can we do to help you feel better?" is not the best response because it does not directly address the client's statement of hopelessness and despair, which requires immediate attention. In an educational context, nurses must be equipped to handle sensitive situations like these with empathy and professionalism. It is crucial to prioritize the client's well-being, follow ethical guidelines, and seek appropriate support or intervention when needed to ensure the best possible outcomes for the client.
Question 3 of 5
Which one of the following goals of therapeutic communication would the nurse strive to attain first?
Correct Answer: A
Rationale: The feedback states establishing a therapeutic relationship is a primary responsibility, but the correct answer is A, suggesting a possible mismatch. Facilitating emotional expression is often the first step within that relationship to build trust and openness. B is broader and ongoing, while C and D follow after rapport is established. Emotional expression initiates the therapeutic process.
Question 4 of 5
A patient states, 'I feel fine. It's a good day.' The nurse notes the patient looking away, and a decreasing pitch in his voice while speaking. Which of the following is the most therapeutic response by the nurse?
Correct Answer: D
Rationale: The correct answer is option D: "You say you feel fine, but you don’t really sound fine." This response demonstrates therapeutic communication by acknowledging the patient's verbal and nonverbal cues. It reflects active listening and encourages the patient to explore their feelings further, fostering a deeper therapeutic relationship. Option A ("I'm glad you are feeling good today.") fails to address the discrepancy between the patient's words and nonverbal cues, missing an opportunity to explore the patient's true feelings. Option B ("I'm not sure I believe you.") is confrontational and may make the patient defensive, hindering effective communication. Option C ("Tell me what is good about today.") is a closed-ended question that does not address the incongruence observed by the nurse. In an educational context, understanding and practicing therapeutic communication skills are essential for nurses working in behavioral health settings. It is crucial to recognize and respond to both verbal and nonverbal cues to provide holistic and patient-centered care. By choosing the correct response, nurses can encourage patients to express their feelings openly, leading to a more accurate assessment and better outcomes in their care.
Question 5 of 5
A patient remarks, 'You know, it's the same thing every time.' The nurse should respond by stating,
Correct Answer: C
Rationale: In this scenario, the correct response is option C) "I'm not sure what you mean. Please explain." This response is appropriate because it shows active listening and demonstrates the nurse's willingness to understand the patient's perspective further. Option A) "I understand" may come across as dismissive or could imply that the nurse already knows what the patient is trying to communicate, which may not be the case. Option B) "I'm sure everyone is doing their best" makes assumptions about the situation without seeking clarification from the patient, which can lead to misunderstandings. Option D) "It's the same thing every time?" is a closed-ended question that does not encourage the patient to elaborate on their feelings or concerns. In an educational context, it is crucial for nursing students to learn effective communication skills, especially in behavioral health settings where understanding and addressing patients' emotions and concerns are essential. Active listening, open-ended questions, and seeking clarification are key components of building therapeutic relationships with patients and providing patient-centered care. By choosing option C, the nurse shows empathy, encourages open communication, and fosters a trusting relationship with the patient.