J. “Have you tried to count back from 100 or listen to music?” Correct K. “The next time this happens, try telling the voices to go away.” L. “Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening.” Rationale: Distracting ways of coping with voices include reading aloud, describing an object in detail, listening to music, and watching television. Having the client try to count back from 100 or listen to music will assist in distraction. In the remaining options, the nurse suggests interacting techniques that reinforce the client’s belief that the voices are real. 73.ID: 383728308 A client who is experiencing suicidal thoughts says to the nurse, “It just doesn’t seem worth it anymore. Why shouldn’t I just end it all?” Which of the following statements should the nurse use to gather additional data from the client? M. “Did you sleep at all last night?” N. “Tell me what you mean by that.” Correct O. “I know you’ve had a stressful night.” P. “I’m sure that your family is worried about you.” Rationale: The correct statement allows the client to tell the nurse more about what the current thoughts are, a therapeutic communication technique. The incorrect options are statements that change the subject and block communication. Test-Taking Strategy: Note the strategic words “gather additional data” in the question. Eliminate
the options that do not relate directly to assessment of the client. From the remaining options, select the one that involves the use of a therapeutic communication technique. The correct option also relates to the subject of the question and provides the opportunity for the client to express thoughts. Review therapeutic communication techniques if you had difficulty with this question. . 5. 74.ID: 383728300 A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, “I need to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get me into a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic? A. Sending the client to the psychiatric hospital intake center immediately for evaluation B. Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately C. Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide Correct Rationale: The client is clearly using suicide as a threat so that he will be hospitalized. As long as self-harm is not an issue, providing the client with shelter will meet his needs. Sending the client to the psychiatric hospital intake center immediately for evaluation is an intervention that should be used if the client refuses to sign a contract for “no suicide.” Guaranteeing the client a
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- Spring '19