Which statement demonstrates a well-structured attempt at limit setting?

Correct Answer: A

Rationale: Choice A, 'Hitting me when you are angry is unacceptable,' demonstrates a well-structured attempt at limit setting because it clearly defines the unacceptable behavior without ambiguity. This statement sets a clear boundary and clearly communicates the consequence for the behavior. In contrast, choices B, C, and D are less effective in setting limits as they are either vague expectations or commands without specific consequences for crossing the limit.

Correct Answer: B

Rationale: In cognitive-behavioral therapy, recognizing and challenging negative thoughts is crucial for progress. Choice B demonstrates the patient's ability to identify and correct distorted thoughts, indicating positive advancement in therapy. This cognitive restructuring is a key component of cognitive-behavioral therapy, helping individuals develop healthier thinking patterns and coping strategies.

Correct Answer: C

Rationale: During an admission assessment and interview, the nurse must actively engage with and monitor multiple communication channels to gather comprehensive patient information. The correct answer is **C: Written**, as it is the least applicable channel during an active, real-time assessment where direct interaction is prioritized. **Why C (Written) is the incorrect choice (and doesn't apply):** Written communication, such as medical records or notes, is passive and retrospective. While it provides valuable background information, it is not a channel the nurse actively *monitors* during the live assessment. The nurse may reference written data, but the assessment primarily relies on real-time, dynamic interactions. Written communication lacks immediacy and does not involve direct patient engagement, making it the least relevant channel for active monitoring in this context. **Why A (Auditory) is essential and applies:** Auditory communication is critical as the nurse listens to the patient’s verbal responses, tone, and speech patterns. This channel provides direct information about the patient’s mental status, emotional state, and subjective symptoms (e.g., pain descriptions). Active listening helps identify inconsistencies, concerns, or cues that require follow-up. Ignoring auditory input would result in missing vital verbalized patient needs or history details. **Why B (Visual) is essential and applies:** Visual observation allows the nurse to assess nonverbal cues, such as body language, facial expressions, and physical appearance. These cues reveal discomfort, anxiety, or signs of illness (e.g., pallor, sweating). Visual monitoring also includes observing the patient’s environment for safety hazards or adaptive equipment use. Without visual attention, the nurse may overlook critical clues that inform care decisions. **Why D (Tactile) is essential and applies:** Tactile communication involves touch, a key component of physical assessment (e.g., palpating pulses, checking skin temperature, or assessing edema). Touch also conveys empathy and reassurance, which can ease patient anxiety. Tactile cues provide objective data (e.g., muscle rigidity or tenderness) that cannot be obtained through other channels. Neglecting tactile monitoring would compromise the accuracy of the physical exam. In summary, while auditory, visual, and tactile channels are actively monitored during the assessment to gather real-time, interactive data, written communication serves as supplemental rather than a primary channel for immediate observation. The nurse’s focus is on dynamic, patient-centered interaction, making written information secondary in this context.

Correct Answer: A

Rationale: The correct answer is A. Patients value interactions with healthcare providers who express genuine acceptance, respect, and concern for their well-being. By focusing on conveying these qualities, a nurse can help alleviate fears of saying the wrong thing as patients appreciate the sincerity and empathy in the communication. This approach fosters trust and a positive therapeutic relationship, enhancing the effectiveness of patient-nurse communication.

Correct Answer: B

Rationale: Choice B is the most therapeutic response as it acknowledges the discrepancy between the patient's verbal statement and nonverbal cues. By addressing both the patient's expressed anticipation and the conflicting nonverbal cues of frowning and avoiding eye contact, the responder demonstrates attentiveness to the patient's emotional state and encourages further exploration of underlying feelings. This approach fosters open communication and helps the patient feel understood and supported.