Question 1

The nurse can use self-disclosure with a client if?

Accepted Answer

Answer reason: Self-disclosure in therapeutic communication is used sparingly and only when it is likely to benefit the client’s treatment outcomes. The nurse’s personal information should never shift the focus away from the client or meet the nurse’s own emotional needs. Even if the client asks directly or it might make conversation easier, the guiding criterion is whether it supports the client’s therapeutic progress and maintains professional boundaries.
Category reason: This question tests appropriate use of nurse communication techniques and professional boundaries in a client interaction, which is best categorized under Therapeutic Communication.

Question 2

The nurse who uses self-disclosure should?

Accepted Answer

Answer reason: Self-disclosure is a therapeutic communication technique used sparingly and only when it benefits the client’s needs. The nurse should briefly share and then immediately redirect the interaction back to the client to maintain focus on the client’s feelings, concerns, and goals. Prolonged discussion about the nurse can shift the relationship away from therapeutic purpose, blur boundaries, and reduce the client’s opportunity to explore their own experience.
Category reason: This question tests appropriate use of self-disclosure and maintaining therapeutic boundaries in nurse–client interactions, which is a core Therapeutic Communication skill.

Question 3

A client with unstable angina asks, “Am I having a heart attack?” Which is the nurse’s best response?

Accepted Answer

Answer reason: This response is honest, calming, and therapeutic without giving a definitive medical diagnosis or false reassurance. Unstable angina can signal imminent myocardial infarction risk, so it is unsafe to label it as a heart attack or to minimize symptoms as “stable.” It also demonstrates active care and ongoing assessment, which supports the client’s anxiety and encourages continued reporting of symptoms while further evaluation (ECG, troponins) proceeds.
Category reason: This item tests how the nurse should respond to an anxious client’s question using safe, supportive communication rather than biomedical detail, making it a Therapeutic Communication NCLEX-style judgment question.

Question 4

Which of the following factors is most important in determining the success of relationships used in delivering nursing care?

Accepted Answer

Answer reason: Therapeutic nurse–client relationships depend primarily on clear, purposeful exchange of information and feelings to build trust, establish goals, and support coping. Communication skills (active listening, empathy, clarification, and appropriate boundaries) are modifiable and directly influence patient understanding, adherence, and satisfaction. While illness type, personalities, and transference phenomena can affect interactions, skilled communication is the core factor that consistently determines relationship effectiveness across clinical situations.
Category reason: This item tests the nursing skill that underpins therapeutic relationships and psychosocial care—using communication techniques to build and maintain an effective nurse–client relationship—so it maps to Therapeutic Communication.

Question 5

A client with schizophrenia says, “The TV is talking about me.” What is the most therapeutic nursing response?

Accepted Answer

Answer reason: This response uses empathy and focuses on the client’s feelings without validating the delusion. It helps build rapport and supports reality-based coping by acknowledging distress rather than arguing about the content. In contrast, confronting or dismissing the belief can increase defensiveness and anxiety, while probing details may unintentionally reinforce the delusional framework.
Category reason: This question tests the nurse’s therapeutic communication strategy when responding to a client experiencing delusions, which is a psychosocial nursing care skill.

Question 6

Scenario: A family member is upset about a delay in treatment. Q. What is the most therapeutic response by the nurse?

Accepted Answer

Answer reason: It acknowledges the family member’s emotions and invites them to share concerns, which helps de-escalate frustration and builds rapport. This open-ended approach supports problem-solving and allows the nurse to assess needs, provide information, and set appropriate expectations. The other options are defensive, dismissive, or prematurely pass off communication, which can worsen conflict and does not address the immediate emotional distress.
Category reason: This question tests the nurse’s use of empathetic, de-escalating language to manage an upset family member, which is a core therapeutic communication skill within Psychosocial Integrity.

Question 7

Scenario: A middle-aged man expresses embarrassment about his new colostomy bag leaking gas in public. Q. What is the most therapeutic nursing response?

Accepted Answer

Answer reason: This response acknowledges the client’s feelings and offers a concrete coping resource without minimizing or dismissing the concern. Facilitating connection with a peer supports adaptation, normalizes experiences in a validating way, and can improve self-efficacy through shared problem-solving. The other options are nontherapeutic because they give premature reassurance, minimize the concern, or offer generalized statements that can feel dismissive.
Category reason: This item tests the nurse’s use of therapeutic communication to support coping and adaptation to a new body-image and lifestyle change (colostomy).

Question 8

How does the nurse respond to a patient using challenging behavior?

Accepted Answer

Answer reason: Therapeutic communication helps de-escalate difficult interactions while preserving patient dignity and maintaining safety. It focuses on understanding triggers, setting clear limits, and using calm, respectful techniques rather than punitive or avoidant responses. Simply relocating the patient, demanding they stop, or ignoring the behavior can escalate agitation, miss underlying unmet needs (pain, fear, confusion), and undermine rapport. A structured therapeutic response supports behavior management and reduces risk of further conflict.
Category reason: This question tests the nurse’s appropriate communication and de-escalation response to difficult patient behavior, which is primarily a psychosocial nursing intervention.

Question 9

The nurse is caring for a client who is experiencing psychosis. The client states, "You all are trying to kill me!" Which of the following responses would be most appropriate for the nurse to make to the client?

Accepted Answer

Answer reason: C. "You are safe here, please be calm." In psychosis with persecutory delusions, the priority is to reduce anxiety and promote safety using calm, simple, reality-oriented statements. This response acknowledges the client’s fear without validating the delusion and communicates safety and support, which helps de-escalate agitation. Directly challenging the belief (e.g., telling the client it is not real) can increase defensiveness and mistrust. Probing the content of the delusion can inadvertently intensify focus on the paranoid belief rather than stabilizing the client.

Question 10

Which of the following statements would be effective therapeutic communication for a client who is struggling with severe depression?

Accepted Answer

Answer reason: B. "I'd like to just sit with you for a while Steve" Therapeutic communication for severe depression emphasizes presence, safety, and nonjudgmental support while the client may have low energy and limited ability to engage. Offering to sit quietly conveys acceptance and willingness to stay with the client without pressuring them to talk, which can reduce isolation and build rapport. Asking a leading or potentially confusing question (as in the poorly worded option D) is non-therapeutic and may increase distress. Overly praising group performance (option A) can feel minimizing or incongruent with the client’s internal experience and may shut down further sharing.

Question 11

The RN is caring for a family who just found out that their newborn baby has tetralogy of Fallot. The parents state, "We can't believe our baby is going to die!" Which of the following statements by the RN is most appropriate?

Accepted Answer

Answer reason: C- Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect. Therapeutic communication uses truthful, supportive information and encourages discussion to reduce anxiety and promote coping. This response acknowledges the situation while providing accurate hope based on the availability of surgical repair, and it invites the parents to share concerns and learn what to expect. It avoids false reassurance that could damage trust and does not minimize or compare their grief. It also redirects toward education and planning, which helps families regain a sense of control after distressing news.

Question 12

What type of interview is most appropriate when a nurse admits a client to a clinic?

Accepted Answer

Answer reason: An open-ended, client-centered approach helps clarify symptoms, health behaviors, and psychosocial factors that may not emerge with closed questions. This style supports accurate assessment and individualized care planning early in the encounter. A more directive approach can be useful later to confirm specifics, but it risks limiting disclosure and missing key cues during intake.

Question 13

How can a nurse best evaluate the effectiveness of communication with a client?

Accepted Answer

Answer reason: Direct client feedback (e.g., teach-back, summarizing, asking clarifying questions) measures whether the nurse’s message was understood as intended and whether the client feels heard. Physiologic responses can reflect stress or comfort but are nonspecific and can be influenced by pain, medications, or illness. Medical assessments and team conferences support care planning, but they do not directly verify the accuracy and impact of the nurse-client communication exchange.

Question 14

A client says, “I feel like life isn’t worth living anymore.” What is the nurse’s best response?

Accepted Answer

Answer reason: ” When a client expresses possible suicidal ideation, the priority is therapeutic communication that invites disclosure and assesses risk while conveying empathy and willingness to listen. An open-ended, nonjudgmental response encourages the client to verbalize feelings and provides an entry point for further direct suicide assessment (e.g., plan, means, intent) and safety interventions. Responses that give advice, minimize, or offer premature reassurance can shut down communication and increase isolation. Guilt-inducing or distracting statements can worsen hopelessness and do not address the immediate safety concern.

Question 15

Of the following, which would NOT be helpful to include when developing Jerry's plan of care?

Accepted Answer

Answer reason: Involving the patient in planning (within safe limits) helps reduce resistance, increases a sense of control, and strengthens the therapeutic relationship. Providing structure can be beneficial to reduce anxiety and promote predictable routines, and PRN medications may be part of a safe symptom-management plan when clinically indicated. In contrast, broadly restricting choices tends to undermine autonomy and can escalate agitation or nonadherence unless there is a clear immediate safety rationale.

Question 16

A client with a new colostomy states, “I’m afraid to go out in public now.” What is the nurse’s best response?

Accepted Answer

Answer reason: ” Therapeutic communication prioritizes empathy and open-ended assessment to explore the client’s feelings and identify specific fears (e.g., odor, leakage, altered body image). An open invitation encourages expression, helps normalize adjustment concerns, and gives the nurse data to tailor teaching and coping strategies. Responses that minimize, give false reassurance, or advise avoidance can shut down communication and reinforce anxiety. This approach supports adaptation to a new ostomy while maintaining dignity and autonomy.

Question 17

A nurse is caring for Mrs. T, a client with expressive aphasia. During a bath, she begins to gesture wildly and point toward the bath water, yet is unable to say anything. Which response from the nurse is most appropriate?

Accepted Answer

Answer reason: Clients with expressive aphasia often understand but cannot produce speech, so the nurse should use simple, specific yes/no questions tied to the immediate context. This option directly validates the client’s nonverbal cue (pointing at the water) and helps rapidly identify a potential safety/comfort issue such as water that is too hot or too cold. It also reduces frustration by offering an easy way to respond (nodding, shaking head, continued pointing). A more vague question invites complex language output and delays addressing a possible immediate problem, while dismissive or distracting responses are nontherapeutic.

Question 18

All of the following statements are true regarding the value of play except?

Accepted Answer

Answer reason: Using play (including medical play, dolls, and games) helps the nurse assess fears, explain procedures in a developmentally appropriate way, and foster cooperation during hospitalization. Therefore, stating it is not effective contradicts established pediatric psychosocial care principles. The other statements reflect well-known developmental benefits of play, including skill-building, emotional mastery, and age-appropriate learning.

Question 19

A client with a history of intimate partner violence has been diagnosed with posttraumatic stress disorder. The client is wholly unwilling to discuss any aspects of personal history or current mental status with the nurse. What is the nurse’s best initial action?

Accepted Answer

Answer reason: Demonstrating empathy, validating feelings, and using nonjudgmental presence are therapeutic communication techniques that reduce perceived threat and can gradually increase engagement. Initiating formal trauma-focused therapies is not an initial bedside nursing action and is unlikely to be effective without a therapeutic alliance and readiness to participate. Withdrawing communication until the client initiates is nontherapeutic, can reinforce avoidance, and may worsen isolation and distrust.

Question 20

A client who is a bus driver was involved in an accident in which two of her passengers died. The client blames herself for their death even though she was exonerated in the follow-up investigation. To help the client see the event more realistically, the nurse should?

Accepted Answer

Answer reason: Cognitive restructuring targets maladaptive, self-blaming thoughts by identifying distortions and replacing them with balanced interpretations grounded in evidence. This directly addresses the client’s inaccurate belief of personal responsibility despite being exonerated, helping her appraise the event more realistically and reduce guilt. EMDR is more specifically aimed at trauma processing and intrusive re-experiencing symptoms rather than correcting a primary cognitive distortion about blame. Benzodiazepines and SSRIs may help anxiety or depressive symptoms but do not directly correct the faulty attribution driving the distress and are not first-line for resolving distorted guilt appraisals.

Question 21

A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?

Accepted Answer

Answer reason: " An objective response uses neutral, factual, patient-centered information rather than opinions, judgments, or defensiveness. This statement explains the clinical rationale for dim lighting at night as a sleep-promoting intervention and addresses the concern with a clear, observable purpose. In contrast, saying staff prefer less light is subjective and staff-centered, and telling the visitor it’s time to sleep is judgmental and likely to escalate conflict. Offering to share a research study can sound argumentative and does not directly address the immediate concern in a simple, therapeutic manner.

Question 22

A client states to the nurse, "I just can't talk in front of the group." The client begins pacing with muscles tightening and irritability. Which action by the nurse will address this level of anxiety?

Accepted Answer

Answer reason: Moderate-to-severe anxiety narrows perceptual field and increases autonomic arousal, so the priority is immediate anxiety reduction and restoration of coping. Remaining with the client provides safety, decreases feelings of being overwhelmed, and models calm behavior, while a low, steady voice helps de-escalate physiologic activation. Pushing the client to “overcome” the fear or sending them back to the group prematurely can intensify anxiety and worsen behavioral dysregulation. Leaving the client alone risks escalation and does not provide therapeutic support when anxiety is impairing functioning.

Question 23

The nurse observes a client that is attending their first group therapy session, exhibiting anxious behaviors. Which is the priority action for the nurse to take to promote comfort when attending the session?

Accepted Answer

Answer reason: Anxiety in a first-time group setting is best reduced by the nurse using a calm, supportive, nonjudgmental approach that models emotional control and conveys safety. A composed demeanor and gentle encouragement help build trust and reduce perceived threat, which directly promotes comfort and increases the likelihood of participation. Offering a choice to delay can reinforce avoidance and may worsen anticipatory anxiety rather than helping the client acclimate. Using guilt or coercive statements is nontherapeutic and can increase anxiety, resistance, and shame.

Question 24

The nurse is caring for a client that begins crying uncontrollably and states, "I am so scared to be here, what if I die?" Which is the best response by the nurse?

Accepted Answer

Answer reason: Acute anxiety and panic can impair a client’s ability to process information, so the priority is immediate support and symptom reduction using simple, concrete interventions. Guiding the client through controlled breathing is a grounding technique that helps decrease physiologic arousal and restores a sense of control, which can then allow further assessment of fears and coping. The reassurance statement minimizes the client’s stated fear and can shut down communication rather than validating and assisting. The other responses are judgmental or dismissive and can escalate distress by implying the client’s reaction is inappropriate.

Question 25

A client has developed posttraumatic stress disorder (PTSD) after a violent sexual assault committed by a close family member. When planning this client's care, the nurse should follow what guideline?

Accepted Answer

Answer reason: Unnecessary touch can trigger flashbacks, hypervigilance, and re-experiencing symptoms, which can undermine trust and worsen anxiety. Limiting touch unless required for care and obtaining explicit permission when touch is needed supports autonomy and reduces the risk of retraumatization. Having a colleague present is not routinely indicated and may feel threatening or punitive, while discouraging social support or discouraging prescribed medications conflicts with evidence-based PTSD care.

Question 26

A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated. How should the nurse respond?

Accepted Answer

Answer reason: “Well differentiated” is a pathology description related to how closely cells resemble normal tissue and generally suggests a slower-growing, less aggressive tumor than poorly differentiated cells, but it does not mean the tumor is benign. By first asking what the provider explained, the nurse identifies knowledge gaps and avoids providing inaccurate or overly definitive statements. This approach also supports the client emotionally by inviting questions and tailoring education based on what the client already knows.

Question 27

The nurse is planning care for a child recently admitted for Guillain-Barré Syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the parents ask about the paralysis, what is the best response by the nurse?

Accepted Answer

Answer reason: ” Guillain-Barré syndrome is typically an acute immune-mediated demyelinating neuropathy in which weakness is usually reversible with gradual neurologic recovery. Families need accurate, realistic teaching that offers hope without false reassurance, especially when respiratory muscle weakness requires ventilation. Recovery commonly occurs over months and can take 1–2 years, making a time-framed explanation both honest and supportive. Statements implying permanent paralysis are incorrect, and promising a specific recovery sequence is unreliable. Sensory symptoms can occur, but frank sensory loss is not the key expected message and does not address the parents’ main concern about prognosis.

Question 28

A female client with breast cancer is confused and concerned about choosing the right course of therapy for her and her family. An intervention the nurse can use to support the client would be to?

Accepted Answer

Answer reason: Nursing support in complex cancer decision-making centers on therapeutic communication that promotes informed, values-based choices while preserving client autonomy. A family meeting creates a structured setting to clarify the client’s understanding, explore goals and concerns, and align family support with what the client wants. This approach reduces anxiety and confusion by improving information sharing and decreasing conflicting messages from relatives. In contrast, pushing independent decisions or shifting decisions to the spouse risks undermining the client’s autonomy and increasing distress rather than strengthening coping.

Question 29

Which intervention best demonstrates the nurse's sensitivity to a 16 year-old's appropriate need for autonomy?

Accepted Answer

Answer reason: Offering time to talk without parents present supports autonomy while maintaining a therapeutic nurse–patient relationship and encourages honest disclosure about sensitive topics (e.g., sexuality, substance use, mood, adherence). This intervention also respects emerging decision-making capacity and can improve engagement in care planning. In contrast, focusing on body image or resentment may be helpful assessments but does not as directly operationalize autonomy as protecting private communication.

Question 30

The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered?

Accepted Answer

Answer reason: In many Native American cultures, sustained direct eye contact can be interpreted as disrespectful, intrusive, or challenging, particularly with authority figures. Recognizing this helps the nurse avoid mislabeling a respectful communication style as evasive or uncooperative and supports accurate data collection during the history. A common pitfall is assuming eye contact is universally a sign of honesty and engagement, which can inadvertently damage rapport in cultures where lowered gaze conveys respect.

Question 31

Which therapeutic communication skill is most likely to encourage a depressed client to vent feelings?

Accepted Answer

Answer reason: Using attentive silence, minimal encouragers, reflection, and clarification helps a depressed client explore and “vent” feelings while strengthening rapport. Confrontation tends to increase defensiveness and can shut down disclosure, especially in depression where guilt and low self-worth are common. Reality orientation is mainly used for confusion/delirium and does not specifically facilitate emotional expression. Projective identification is a defense mechanism/psychodynamic concept, not a frontline therapeutic communication skill for eliciting feelings.

Question 32

A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “I refuse both radiation and chemotherapy because they are ‘hot.’ ” The next action for the nurse to take is to?

Accepted Answer

Answer reason: The statement suggests a cultural or personal interpretation of treatment (e.g., “hot/cold” health beliefs), so the nurse should assess understanding and concerns to address misconceptions and support informed decision-making. Involving family or notifying the provider may be appropriate later, but only after clarifying the client’s perspective and ensuring the refusal is informed. Documentation is required but is not the best immediate action because it does not resolve the communication barrier or support the client’s decision process.

Question 33

A nurse and client are talking about the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?

Accepted Answer

Answer reason: Discussing the client’s progress in understanding stress-related behavior reflects a summary and appraisal of outcomes rather than initial problem identification. In contrast, the orientation phase focuses on establishing trust, defining roles, and setting preliminary goals. The working phase emphasizes active intervention and exploration to produce change, whereas this stem highlights evaluating that change.

Question 34

A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?

Accepted Answer

Answer reason: An initial listening response invites the client to elaborate on fears and guilt, helping the nurse determine whether this is anxiety, intrusive thoughts, or a spiritual/moral concern requiring later support. Calling a chaplain may be appropriate after assessment but is not the first step because it bypasses exploration of the client’s emotional state. Denying feelings and citing recovery statistics are nontherapeutic and can invalidate the client’s distress, increasing anxiety and shutting down communication.

Question 35

A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." An appropriate response for the nurse is?

Accepted Answer

Answer reason: " In therapeutic communication with a client experiencing paranoid delusions, the priority is to acknowledge feelings and promote safety without validating the delusional content. This response reflects the client’s emotion, which can help de-escalate agitation and opens the door to further assessment of triggers and potential risk. It avoids challenging or interpreting the client’s belief about the nurse being “perfect,” which could increase defensiveness or paranoia. By focusing on the observable affect, the nurse maintains a nonjudgmental stance and supports reality-based interaction.

Question 36

The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is?

Accepted Answer

Answer reason: " Therapeutic communication with delusions focuses on exploring the client’s perception and feelings while avoiding validating the false belief. This option uses a neutral, clarifying reflection that encourages the client to talk without agreeing that poisoning is real. In contrast, offering reassurance that no one will poison them implicitly accepts the delusion and can reinforce it. Asking “why” can feel confrontational and increase defensiveness, and labeling it as illness too early can shut down communication before rapport is established.

Question 37

Therapeutic nurse-client interaction occurs when the nurse?

Accepted Answer

Answer reason: Helping a client clarify what they meant encourages accurate understanding, explores feelings, and supports the client’s own problem-solving. Interpreting covert communication risks imposing the nurse’s assumptions rather than eliciting the client’s perspective. Praise can shift focus to the nurse’s approval and may inhibit exploration, while advising gives solutions and can foster dependence rather than autonomy.

Question 38

A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client's attire?

Accepted Answer

Answer reason: Escorting her privately to her room and helping her change resolves the immediate problem with minimal embarrassment and without confronting or shaming her in front of others. Statements that compare her to others or imply ridicule can escalate defensiveness, worsen agitation, or harm rapport. Education about unit expectations can be provided after privacy is restored, but immediate action should focus on discreetly removing her from the public setting.

Question 39

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?

Accepted Answer

Answer reason: "You look upset. Would you like to talk about it?" Therapeutic communication uses reflection and open-ended invitations that center the client’s feelings and allow them to choose whether to share. This statement names the observed emotion without judgment and offers the client control, which supports rapport and further assessment. In contrast, shifting to the nurse’s personal reactions is self-focused and can shut down sharing, while asking “how long” can feel interrogative and may imply the emotion is a problem to be justified. The goal is to facilitate expression and exploration of feelings in a safe, client-led way.

Question 40

A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse?

Accepted Answer

Answer reason: Seeking more information allows the nurse to evaluate the degree of preoccupation, potential risk, and associated emotions while maintaining a neutral, reality-based stance. Remaining silent can appear dismissive and shuts down rapport, whereas direct confrontation typically increases defensiveness and agitation. Escalating the belief by involving outside authorities reinforces the delusion and is unsafe unless there is a clear, specific threat that requires emergency action.

Question 41

A Hispanic client in the postpartum period refuses the hospital food because it is “cold.” The best initial action by the nurse is to?

Accepted Answer

Answer reason: Exploring what is considered acceptable versus “bad” food identifies cultural postpartum dietary practices and the meaning of “cold,” which may be tied to hot/cold health beliefs and affects intake. This approach builds rapport, avoids stereotyping, and guides an individualized plan that can then include warming food or alternative choices. Delegating reheating or immediately consulting a dietitian may be helpful later, but they are not the best first step because they occur before clarifying the patient’s needs and expectations. Simply encouraging eating is non-therapeutic and risks dismissing the patient’s stated concern.

Question 42

A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to?

Accepted Answer

Answer reason: Addressing the behavior directly by clarifying roles, expectations, and limits helps the client understand what is acceptable while preserving rapport and safety on a locked unit. This approach is nonjudgmental and redirects the interaction toward therapeutic goals rather than personal validation. Simply labeling the behavior “inappropriate” or citing policy can sound punitive and may escalate defensiveness without teaching appropriate interpersonal limits. Avoiding the client by changing assignments does not resolve the boundary issue and can undermine continuity of care.

Question 43

The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?

Accepted Answer

Answer reason: A nonjudgmental response encourages them to share concerns, reduces defensiveness, and supports coping so they can participate effectively in the child’s care. Teaching about causes or focusing solely on recovery can prematurely redirect the conversation and miss the emotional need driving the statement. Agreeing that they should have sought earlier care reinforces guilt and may damage the nurse–family relationship. The most supportive, clinically appropriate approach is to accept feelings and provide empathetic presence before offering further education.

Question 44

Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills?

Accepted Answer

Answer reason: One-to-one interactions are easier to tolerate, allow the nurse to model communication, and support success experiences that can be expanded gradually. Pushing immediate interaction with a larger peer group can increase anxiety and reinforce withdrawal rather than build skills. Focusing on interpreting the meaning of withdrawal is less effective early on than providing structured, achievable opportunities to practice relating.

Question 45

A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is?

Accepted Answer

Answer reason: " Therapeutic communication uses open-ended, nonjudgmental questions to explore the patient’s concerns and barriers to adherence. This response invites the client to identify specific issues (e.g., side effects, stigma, fear, misunderstanding) so the nurse can provide targeted education, problem-solving, and collaboration with the prescriber. In contrast, statements that pressure, threaten, or coerce undermine trust and can escalate resistance. Simply postponing the discussion avoids addressing a potentially urgent treatment need and misses an opportunity to engage the client in shared decision-making.

Question 46

A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." The nurse's best response would be which of these statements?

Accepted Answer

Answer reason: This situation calls for therapeutic communication that reflects the client’s expressed feeling and meaning without judging or shifting topics. A focused reflection helps the client feel heard and encourages further exploration of fears about intimacy and acceptance after possible mastectomy. This option accurately mirrors the client’s stated concern (anticipated partner avoidance) in neutral language, which is more therapeutic than probing into sexuality or offering a more abstract interpretation. It also avoids minimizing the worry or prematurely reassuring, allowing assessment of coping and support needs.

Question 47

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states, " This is not my baby, and I do not want it." The nurse's best response is?

Accepted Answer

Answer reason: " Therapeutic communication prioritizes acknowledging the client’s feelings, assessing for underlying distress, and inviting elaboration with open-ended questions. This response validates the mother’s affect and creates space to explore potential postpartum mood disorders, psychosis, bonding difficulties, or trauma while maintaining rapport. The other options minimize, give false reassurance, or redirect with superficial praise, which can shut down communication and miss safety risks given the infant’s unsafe position at the bed’s edge. An open invitation to discuss the experience supports assessment and guides timely interventions to protect both mother and newborn.

Question 48

A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to?

Accepted Answer

Answer reason: This approach reduces anxiety, supports safety, and creates the foundation for later participation in milieu and structured activities. Trying to persuade the client out of the belief typically increases defensiveness and can worsen suspicion. Group activities are usually introduced gradually after rapport is built, and routine isolation from peers is not indicated unless there is a specific safety risk.

Question 49

A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?

Accepted Answer

Answer reason: Allowing the mother to verbalize concerns creates rapport and provides assessment data about postpartum adjustment, anxiety, and beliefs about parental roles. After emotions and meaning are clarified, the nurse can then provide targeted education and negotiate shared caregiving in a way the mother can tolerate. Immediately pushing shared responsibilities or classes risks increasing defensiveness and shutting down communication. Siding with the father against the mother undermines trust and can intensify conflict rather than supporting family adaptation.

Question 50

While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best?

Accepted Answer

Answer reason: " Therapeutic communication starts with assessing the client’s perspective to identify concerns (e.g., side effects, fear, misunderstanding, cost, cultural beliefs) before attempting teaching or escalation. This open-ended question is nonjudgmental and invites the client to share the underlying reason, which guides safe, individualized next steps such as education, symptom management, or contacting the prescriber if appropriate. Telling the client it’s fine to skip doses minimizes the risk of harm and undermines adherence. Threatening to “report” or immediately emphasizing consequences can feel coercive and may shut down communication, rather than addressing the refusal constructively.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Therapeutic Communication NCLEX Practice Test

Continue Learning