Question 1

A client with terminal cancer tells the nurse, “I’ve given up. I have no hope left. I’m ready to die.” What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Therapeutic communication prioritizes reflection and open-ended exploration to help a client express feelings and meaning without judgment. This response mirrors the client’s statement and invites elaboration, which is appropriate in end-of-life discussions where emotions, values, and goals of care need to be clarified. Redirecting to other team members can feel dismissive and prematurely shuts down the nurse-client relationship at a critical moment. Offering false reassurance or implying cures is not realistic for terminal illness and can invalidate the client’s experience and distress.

Question 2

The client with a newly created colostomy is concerned about having satisfying sexual relations. What should the nurse recommend?

Accepted Answer

Answer reason: Supporting sexual function after ostomy creation focuses on practical measures that reduce anxiety about odor, leakage, and unexpected output while preserving normal intimacy. Emptying and cleansing the pouch immediately beforehand minimizes bulk and noise and helps the client feel more confident and comfortable during intercourse. Recommendations that restrict intimacy to darkness or substitute masturbation reinforce stigma and can worsen body-image distress rather than promote healthy adaptation. Mandating a single sexual position is unnecessarily limiting; individualized positioning for comfort is appropriate, but no single position is universally required.

Question 3

The client diagnosed with dissociative amnesia is increasingly frustrated and begins to threaten to commit suicide. Which technique should the nurse use to establish a rapid working relationship with the client?

Accepted Answer

Answer reason: Listening attentively to the client’s current presentation helps de-escalate emotion, improves cooperation, and allows immediate assessment of suicide risk and intent. Giving directives to “remain calm” is nontherapeutic and often escalates frustration by minimizing feelings. Bargaining with a “main personality” is inappropriate and can reinforce maladaptive dissociation rather than promoting safety and engagement.

Question 4

The client diagnosed with mania tells the nurse, “I think you’re nice looking. Maybe we could go to my room.” Which response by the nurse is most therapeutic?

Accepted Answer

Answer reason:  Therapeutic communication in mania requires calm, clear limit-setting and maintaining professional boundaries to reduce escalation and protect the client-nurse relationship. This response directly sets an appropriate boundary without shaming the client or engaging in the sexualized content. It avoids making the interaction about the nurse’s feelings, which can increase tension and is not client-centered. Redirecting to activities can be helpful, but it should follow or include explicit boundary-setting to address the inappropriate proposition safely and therapeutically.

Question 5

A client who experienced a myocardial infarction (MI) tells the nurse he is fearful of dying. The most appropriate response by the nurse is?

Accepted Answer

Answer reason:  Therapeutic communication prioritizes acknowledging and exploring the client’s expressed fear to reduce anxiety and support coping. An open-ended invitation encourages the client to verbalize concerns, which helps the nurse assess the intensity of fear, identify misconceptions, and tailor emotional and educational support. Reassurance that “everything will be fine” or that they’ll “feel better soon” offers false reassurance and can shut down further sharing. Statements focused on what the staff is doing may be well-intended but still redirect away from the client’s emotions rather than validating them.

Question 6

The nurse is performing preoperative teaching for a client scheduled for surgery. What should be the primary focus of the teaching?

Accepted Answer

Answer reason: g., breathing exercises, pain plan, activity expectations). Broad, understandable information supports informed participation and decreases anxiety, which can otherwise impair learning and recovery. Deciding whether to proceed is the provider/client informed-consent decision, not the nurse’s role. Providing overly detailed surgical minutiae can increase anxiety and is less helpful than focused, practical expectations and instructions tailored to the client’s needs.

Question 7

What is the best intervention by a nurse to increase an adolescent’s compliance with treatment for diabetes mellitus?

Accepted Answer

Answer reason: Adolescents are more likely to adhere when they feel autonomy, control, and personal relevance in a chronic-care plan. Exploring values and goals supports shared decision-making and helps tailor the regimen to what matters to the teen (school, peers, sports), improving buy-in and follow-through. This approach also identifies barriers such as denial, embarrassment about injections, or conflict with parents so strategies can be individualized. Teaching about long-term complications can be appropriate, but distant consequences are often less motivating for adolescents than immediate, personally meaningful goals. Practical supports like cafeteria diet changes or sports calorie estimates help, but they do not address the primary adherence driver of engagement and ownership.

Question 8

The nurse determines that the best intervention to provide support to the parents of an infant diagnosed with pyloric stenosis would be?

Accepted Answer

Answer reason: Clear, consistent information reduces parental anxiety and supports coping when an infant has a condition requiring hospitalization and likely surgery. The nurse is responsible for ongoing therapeutic communication, including updating parents on status, plan of care, and what to expect, which promotes trust and participation in care. Having the nurse provide all care during visits can increase parental helplessness and impair bonding. Delegating parent-updates to the physician is unnecessary because nurses should provide routine progress updates and reinforce the medical plan within scope.

Question 9

The parents of an infant born with clubfoot express feelings of guilt and anxiety about their child’s condition to the nurse. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Therapeutic communication prioritizes acknowledging and exploring emotions before moving to teaching or problem-solving. Parents expressing guilt and anxiety benefit most from an open-ended invitation to verbalize feelings, which reduces distress and builds trust and coping. Immediate education or referrals can feel dismissive if emotions have not been validated and may not be retained when anxiety is high. Peer support or chaplain services can be helpful later, but first-line nursing care is to facilitate expression and normalize emotional responses.

Question 10

A client with bulimia nervosa asks a nurse, “How can I ask for help from my family?” What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Therapeutic communication uses open-ended, nonjudgmental questions to explore the client’s experience and build insight and coping skills. This response assesses prior attempts and barriers to seeking support, which helps the nurse tailor practical guidance and involve the family appropriately. It conveys acceptance and invites elaboration rather than giving premature advice. In contrast, the other options are judgmental or dismissive and can increase shame or discourage help-seeking, which is counterproductive in eating disorders.

Question 11

A client with schizophrenia tells the nurse that the President consults with him before making major decisions. What is the best response by the nurse?

Accepted Answer

Answer reason: “You must feel important. Now let’s make your bed.” Therapeutic communication with delusions focuses on acknowledging the client’s feelings without validating the false belief, then gently redirecting to reality-based topics. This response reflects the emotion implied by the grandiose delusion while shifting the interaction to a concrete, present-centered activity, which can reduce reinforcement of the delusional content. The other options either explore details of the delusion or implicitly agree with it, which can strengthen the delusion and escalate preoccupation. Redirection to a simple task also supports structure and engagement, which is often helpful in psychotic disorders.

Question 12

A client approaches the nurse and points at the sky, showing her where the men would be coming from to get him. What is the best response by the nurse?

Accepted Answer

Answer reason:  Therapeutic communication with a delusional client focuses on acknowledging the client’s feelings while not validating the delusion. This response reflects the emotion (fear) and offers reassurance about safety in the current setting, which can reduce anxiety and support trust. In contrast, reinforcing statements that promise protection can unintentionally validate the belief and create unrealistic expectations of staff control. Directly challenging the delusion with “facts” is typically ineffective and can increase defensiveness or agitation.

Question 13

A client is admitted to the hospital for scatophilia and tells the nurse that he doesn’t want to talk to her about his sexual behaviors. Which response from the nurse is the most appropriate?

Accepted Answer

Answer reason:  This situation primarily tests therapeutic communication: acknowledging feelings and building rapport increases the likelihood the client will eventually share sensitive information. An empathic statement validates the client’s discomfort without judgment and helps reduce shame, which is especially important in stigmatized sexual behavior concerns. Pressuring the client to complete the database or documenting a dismissive “no comment” can damage trust and shut down future disclosure. While recognizing the client’s right to refuse is respectful, it does not actively facilitate engagement as effectively as empathic reflection does.

Question 14

A 33-year-old female client tells the nurse that she has never had an orgasm. Her partner is upset that he is unable to meet her needs. What is the best intervention by the nurse?

Accepted Answer

Answer reason: Nursing care for sexual concerns begins with open, nonjudgmental assessment to clarify the client’s meaning, expectations, relationship dynamics, contributing stressors, and any physical/psychological factors. Exploring both partners’ perceptions identifies knowledge deficits, unrealistic expectations, communication problems, or mismatch in sexual response that can be addressed with education and counseling. Minimizing the concern is inaccurate and shuts down communication, worsening distress and trust. Assigning a psychiatric diagnosis and referring immediately is premature without assessment and rules out common, modifiable factors that may be managed with initial counseling and appropriate medical evaluation if indicated.

Question 15

What is the most appropriate nursing intervention to increase the selfesteem of a client with conversion disorder?

Accepted Answer

Answer reason: Conversion disorder symptoms are not intentionally produced, and nursing care should avoid reinforcing the sick role by giving disproportionate attention to physical complaints. Emphasizing the client’s strengths, roles, and feelings supports a therapeutic relationship and promotes self-worth without rewarding symptom expression. This approach also helps shift focus toward adaptive coping and functional behaviors. In contrast, intensive exploration of childhood trauma is not a first-line nursing intervention in many settings and can increase anxiety or dependency, while promoting avoidant communication undermines healthy coping. Short-term goals can be helpful, but prioritizing a non–symptom-focused interpersonal approach most directly targets self-esteem and prevents symptom reinforcement.

Question 16

A client with a history of alcohol abuse tells the nurse that he refuses to take his vitamins. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Teaching should be factual, nonjudgmental, and focused on physiologic consequences to support informed decision-making and engagement. Chronic alcohol use commonly leads to nutritional deficiencies (notably thiamine, folate, and other B vitamins) due to poor intake and impaired absorption, so explaining depletion is accurate and relevant. This response avoids false reassurance and avoids making unrealistic promises about cravings or liver healing. It also supports further assessment of the client’s understanding and readiness to participate in treatment, which is more therapeutic than persuasion or minimizing the need for diet.

Question 17

When the nurse is completing the history of the 16-year-old client at a clinic, the client says, “I think that I might be pregnant.” What is the nurse’s best response?

Accepted Answer

Answer reason:  Therapeutic communication begins with an open-ended, nonjudgmental assessment that invites the client to share concerns and cues. This response explores the client’s perceptions (missed period, nausea, unprotected intercourse, home test) and gathers data without implying blame or making assumptions. It also supports rapport with an adolescent who may feel anxious or fearful, improving the likelihood of honest disclosure and follow-up. In contrast, asking about sexual activity or the last menstrual period too early can feel interrogating or narrow the conversation before the client expresses what prompted the concern.

Question 18

A 40-year-old female client is admitted to a women’s shelter after being raped by her estranged husband. The client describes the traumatic event. Which response by the nurse is best?

Accepted Answer

Answer reason: Trauma-informed nursing care prioritizes emotional safety, control, and supportive presence while the survivor shares what they choose to disclose. Attentive listening conveys belief, validation, and respect, which helps reduce isolation and supports acute coping after sexual assault. Redirecting the conversation can communicate discomfort or dismissal and may shut down disclosure. Group processing and sedating to “prevent hysteria” are not first-line immediate responses and can remove autonomy or inhibit appropriate emotional expression and assessment.

Question 19

The nurse is performing an admission assessment. What is the best statement/question for the nurse to use to gather the most information about the reason for admission would be?

Accepted Answer

Answer reason: " Open-ended questions are the best way to elicit a broad, patient-centered narrative during an admission assessment. This phrasing invites the client to describe symptoms, onset, context, concerns, and priorities in their own words, which yields more complete data about the reason for admission. The other options are closed-ended and problem-focused, which can prematurely narrow the assessment and miss key details. A vague statement about questioning pain does not effectively prompt the patient to provide specific, useful information compared with a clear open invitation to share.

Question 20

After abdominal surgery for repair of an aortic aneurysm, a client may show maladaptive coping behavior in response to body changes related to the surgery. Which nursing intervention is best?

Accepted Answer

Answer reason: Therapeutic communication supports adaptive coping by helping the client identify and verbalize emotions about altered body image after major surgery. Allowing expression builds trust, reduces anxiety, and provides the nurse an opportunity to assess the client’s specific concerns and coping patterns before intervening further. Teaching coping strategies or suggesting diversion can be premature and may feel dismissive if the client has not first processed the emotional impact. Referral may be appropriate later if distress is persistent or severe, but the best initial nursing intervention is to facilitate expression and exploration of feelings.

Question 21

A 38-year-old female client is scheduled to have a hysterectomy and is concerned about no longer being a “whole woman.” Which intervention by the nurse is best?

Accepted Answer

Answer reason: Therapeutic communication prioritizes exploring the client’s meaning, fears, and self-image concerns so the nurse can assess coping and provide individualized support. Using open-ended encouragement helps validate emotions, reduces anxiety, and builds trust before moving to education or referrals. Directing her to speak to her husband shifts focus away from the client and assumes readiness and relationship dynamics that may not be present. Providing reading material and leaving is nontherapeutic because it can communicate dismissal and misses an opportunity for immediate emotional support.

Question 22

The nurse is overheard responding to the client who reports sleeping only 3 hours at night. Which statement by the nurse is inappropriate?

Accepted Answer

Answer reason: " Therapeutic communication prioritizes exploring the client’s experience with open-ended questions and reflecting feelings without labeling or diagnosing. This statement prematurely introduces depression and generalizes, which can feel judgmental, shut down further sharing, and does not assess the client’s specific sleep pattern or contributing factors. The other responses either gather more assessment data or gently explore possible stressors while keeping the focus on the client’s perspective. Introducing a mental health diagnosis without adequate assessment is a common communication error in psychiatric nursing.

Question 23

After a right hemicolectomy for treatment of colon cancer, a 57-year-old client is reluctant to turn while on bed rest. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Turning reduces risk of complications such as atelectasis/pneumonia, pressure injuries, and venous stasis, and it can be planned with splinting and analgesia to minimize discomfort. Explaining the purpose and benefits supports informed cooperation and can reduce anxiety or fear of pain that commonly drives refusal. In contrast, citing a physician order is nontherapeutic and can increase resistance, while waiting until the client feels ready can delay essential prevention measures.

Question 24

An adolescent with diabetes tells the community nurse that he has recently started drinking alcohol on the weekends. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Open-ended exploration is the most therapeutic first response because it assesses the adolescent’s motivation, stressors, peer influence, and readiness to change before moving to teaching or referral. Understanding the reason for alcohol use helps the nurse tailor risk-reduction strategies specific to diabetes (e.g., hypoglycemia risk, missed meals, impaired judgment with insulin dosing). Promising to stop is non-therapeutic and rarely effective, often increasing resistance and shutting down communication. Education and counseling referral may be appropriate later, but they are best after assessment and rapport-building clarify the level of risk and needed supports.

Question 25

The nurse is developing a teaching plan for adolescents about acne. The nurse incorporates which characteristic as commonly responsible for the failure of treatment of acne in teenagers?

Accepted Answer

Answer reason: When the parent is driving the decision and the teen is disengaged, daily tasks like consistent cleansing, correct application of medications, and tolerating expected irritation are less likely to be done. This dynamic also increases resistance and inconsistent follow-up, undermining outcomes even when the prescribed therapy is appropriate. In contrast, the specific modality (topical vs systemic) is less predictive of failure than whether the adolescent reliably participates in the plan.

Question 26

An infant is brought to the emergency department (ED) and pronounced dead with the preliminary finding of sudden infant death syndrome (SIDS). Which question to the parents is appropriate?

Accepted Answer

Answer reason:  In a suspected SIDS death, the nurse should use open-ended, nonjudgmental questions that allow parents to describe events and observations without implying blame. This question supports therapeutic communication while also gathering essential assessment details (position, color, secretions, emesis, signs of distress) that can help the team understand the circumstances and guide required reporting and evaluation. In contrast, questions about blankets or sibling jealousy are leading and accusatory, which can escalate guilt and distress and may hinder accurate history-taking. Asking about hearing the infant cry is narrow and less useful than an open description of what was observed at discovery.

Question 27

A 19-month-old child with croup is crying as a nurse tries to auscultate breath sounds. Which intervention by the nurse would be most appropriate?

Accepted Answer

Answer reason: Toddlers commonly become fearful with unfamiliar procedures, and anxiety/crying can worsen upper-airway obstruction in croup by increasing agitation and work of breathing. Allowing the child to handle the stethoscope uses developmentally appropriate, nonthreatening engagement to build trust and reduce distress so assessment can be completed more accurately. Forcing cooperation or separating the parents escalates anxiety and can intensify respiratory symptoms. Attempting to auscultate through persistent crying can also limit the quality of the lung assessment and misses the opportunity to calm the child first.

Question 28

A female client is talking to a nurse about her binge-purge cycle. What is the most appropriate question for the nurse to ask the client?

Accepted Answer

Answer reason:  Therapeutic communication in eating disorders prioritizes neutral, nonjudgmental assessment that gathers specific data needed for safety planning and treatment. Asking about frequency is an open, factual question that helps quantify severity and guides evaluation for medical complications (e.g., dehydration, electrolyte abnormalities, cardiac risk) without reinforcing the behavior. In contrast, questions focusing on weight loss or anxiety relief can validate the maladaptive function of purging and may increase shame or defensiveness. Asking whether she knows how to stop is premature and can sound blaming, rather than exploring the pattern and triggers first.

Question 29

A client with anorexia nervosa is having problems with peer relationships. The nurse determines that which of the following is the best communication strategy?

Accepted Answer

Answer reason: Peer relationship problems in anorexia nervosa often reflect impaired coping skills, low self-esteem, and difficulty identifying and verbalizing emotions. The most therapeutic approach is to build effective interpersonal communication and emotional expression skills so the client can relate to others more appropriately and reduce maladaptive behaviors. Focusing solely on “anxiety causes” can be premature and may increase defensiveness without first developing skills for expression and interaction. Confrontation is nontherapeutic and risks shame, resistance, and further withdrawal, worsening social functioning.

Question 30

A client with avoidant personality disorder says occupational therapy (OT) is boring and he doesn’t want to go. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: Avoidant personality disorder is marked by social inhibition and fear of criticism, so clients often withdraw from group or performance-based activities when anxious. Exploring the client’s perception with an open-ended question is therapeutic communication that builds rapport, identifies specific barriers (e.g., fear of embarrassment, low confidence), and creates an opening to problem-solve engagement. A firm directive can increase anxiety and resistance, especially when the client already feels uncomfortable, and does not address the underlying avoidance. Allowing the client to skip OT reinforces avoidance behavior and decreases opportunities to practice coping and social skills. Arranging an on-unit project may be useful later as graded exposure, but first the nurse should assess the client’s concerns to tailor an appropriate, supportive plan.

Question 31

A 22-year-old schizophrenic client was admitted to the psychiatric unit during the night. The next morning, he began to misidentify the nurse and call her by his sister's name. Which intervention is best?

Accepted Answer

Answer reason: New-onset misidentification in a psychotic disorder is managed with calm, reality-based, nonconfrontational communication and frequent reorientation to reduce confusion and support safety. Early in hospitalization, unfamiliar surroundings and acute psychosis can worsen perceptual disturbances, so providing clear cues about who staff are and where the client is helps ground the client in reality. Simply accepting or reinforcing the misidentification risks validating a distortion and can intensify confusion and dependency. Assessing for violence is important if there are cues of agitation or threats, but the stem presents misidentification without escalation; the most directly therapeutic initial intervention is reorientation.

Question 32

A client makes vague statements with no logical connections. He asks whether the nurse understands. What is the best response by the nurse?

Accepted Answer

Answer reason:  Therapeutic communication with disorganized or loosely associated speech requires honesty, clarity, and a supportive attempt to understand without validating confusion. This response acknowledges the client’s feelings and expresses willingness to listen while reality-orienting that the message is not coherent to the nurse. It also invites the client to clarify, which can reduce anxiety and promote more organized communication. By contrast, delaying the conversation or criticizing the client can increase distrust and further impair rapport, and claiming understanding when you do not is nontherapeutic and misleading.

Question 33

A client has undergone surgery for the repair of an abdominal aortic aneurysm. The client's wife asks the nurse if her husband will be impotent. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: " The key principle is therapeutic communication: provide honest, factual information and acknowledge the client/family’s concern without offering false reassurance or dismissing feelings. Erectile dysfunction can occur after AAA repair due to potential injury or compromised blood flow to pelvic autonomic nerves and vessels, so the nurse should validate the possibility and keep communication open. This response addresses the question directly and supports informed coping and planning. The other options minimize or avoid the concern, which can increase anxiety and reduce trust.

Question 34

A client admitted to the hospital with a diagnosis of pedophilia tells his roommate about his problems. His roommate runs down the hall yelling at the nurse, "I don’t want to be in here with a child molester." Which response from the nurse is most appropriate?

Accepted Answer

Answer reason: "I can see you’re upset. Sit down and we’ll talk." The priority is to use therapeutic communication to acknowledge the roommate’s strong emotion and de-escalate the situation while maintaining a safe milieu. This response reflects feelings, offers support, and invites the client to discuss concerns in a calmer setting, which helps restore behavioral control. It also avoids arguing facts, labels, or disclosing/confirming another client’s diagnosis, which could worsen agitation and violate privacy. Commands or judgmental statements are nontherapeutic and typically escalate distress rather than promoting problem-solving.

Question 35

A 35-year-old client who has been married for 10 years arrives at the psychiatric clinic stating, “I can’t live this lie any more. I wish I were a woman. I don’t want my wife. I need a man.” What is the priority intervention by the nurse?

Accepted Answer

Answer reason: The priority in an initial psychiatric encounter is therapeutic communication to assess distress, clarify the client’s meaning, and establish safety while conveying acceptance and support. An open, nonjudgmental exploration helps the nurse evaluate for acute risk (e.g., hopelessness or suicidal intent implied by “can’t live”) and identify immediate needs before taking action-oriented steps. Automatically involving the spouse or initiating admission can be premature and may escalate anxiety or violate the client’s readiness to disclose. Provider notification may be appropriate after assessment, but the first nursing intervention is to engage, listen, and assess.

Question 36

A female client enjoys wearing men’s clothing. Her sister tells the nurse that the client wishes for a sexual reassignment operation. The client tells the nurse she just wants to be left alone. Which initial nursing intervention is most appropriate?

Accepted Answer

Answer reason: The priority initial action in a sensitive psychosocial concern is to use therapeutic communication to assess the client’s perceptions, distress, and readiness to talk. Inviting expression supports rapport, reduces defensiveness, and helps clarify whether there is confusion, conflict, or simply a preference in clothing without distress or impairment. Confronting with interpretations is nontherapeutic and can increase resistance, especially when the client requests to be left alone. Intervening by attacking the sister or advising avoidance escalates family conflict and does not address the client’s immediate needs or support assessment.

Question 37

A client recovering from alcohol abuse tells the nurse, “I get nothing out of Alcoholics Anonymous (AA) meetings.” What is the best response by the nurse?

Accepted Answer

Answer reason:  Therapeutic communication focuses on exploring the client’s feelings, expectations, and goals to promote insight and motivation for recovery. This open-ended question helps the client clarify what they expected from AA and what needs are unmet, which can guide problem-solving (e.g., trying different meetings, finding a sponsor, or setting realistic goals). It avoids judgment, confrontation, or implying failure, which could increase resistance. In contrast, questions that sound challenging or presume the client will quit meetings can shut down discussion and undermine engagement in treatment.

Question 38

A nurse is working with a client addicted to cocaine who is in denial. What is the most appropriate intervention for the nurse to implement?

Accepted Answer

Answer reason: Denial reflects limited insight and ambivalence, so the most therapeutic nursing approach is to use nonjudgmental, open-ended questions that assess readiness to change and invite self-reflection. This intervention aligns with motivational interviewing principles by eliciting the client’s own perception rather than confronting or arguing, which can increase resistance. Linking use to harmful results can be appropriate later, but if done too directly it may feel confrontational and strengthen denial. Focusing on withdrawal discomfort or pointing out symptoms addresses physiologic effects but does not directly engage the core problem of denial and lack of problem recognition.

Question 39

The newly hospitalized 90-year-old client has difficulty answering the nurse’s questions and reports progressive hearing loss. Which nursing action would best aid in communication between the nurse and client?

Accepted Answer

Answer reason: Brief, simple sentences reduce cognitive load and make it easier for the client to process and respond accurately. Speaking quickly and using a higher pitch worsens comprehension because presbycusis typically affects high-frequency sounds and rapid speech is harder to interpret. Overenunciating or overexaggerating expressions can distort speech/lip movements and may feel patronizing rather than improving clarity.

Question 40

A client’s family experiences acute grief. Which action by the nurse offers the most comfort to the family?

Accepted Answer

Answer reason:  Therapeutic communication in acute grief prioritizes presence, empathy, and validation over teaching or problem-solving. A brief, sincere statement of concern supports the family’s emotional needs and conveys that they are not alone, which is often the most immediately comforting intervention. Philosophical discussion can feel minimizing or abstract when emotions are intense. Giving advice or shifting focus to the nurse’s own story can prematurely direct the interaction away from the family’s feelings and can be perceived as dismissive.

Question 41

An 86-year-old client admitted to the hospital with chest pain is hearing impaired. Which method should be used when assessing the client?

Accepted Answer

Answer reason: Age-related hearing loss typically affects high-frequency sounds first, so using a lower-pitched voice improves audibility. Facing the client supports lip-reading and allows observation of facial cues, improving accuracy of assessment and reducing anxiety. Shouting distorts sound, can be perceived as aggressive, and does not reliably improve comprehension. Waiting for a hearing aid delays urgent assessment for chest pain, whereas adapting communication can be done immediately.

Question 42

The psychiatric home health nurse is planning care for a client with paranoid schizophrenia who was recently discharged from a mental health facility. Which nursing action should be included in the plan of care?

Accepted Answer

Answer reason: Reinforcing moments of accurate perception strengthens reality testing and builds trust without escalating paranoia. Confrontation tends to increase defensiveness and can worsen suspiciousness in paranoid schizophrenia. Family teaching should focus on not validating delusions and gently redirecting rather than attempting to argue or “discourage” them directly, which often heightens agitation.

Question 43

A schizophrenic client states, “The voices keep talking to me. They’re telling me that I have to leave here and that I shouldn’t talk to you. Don’t you hear what they’re saying?” Which response is best?

Accepted Answer

Answer reason:  Therapeutic communication with hallucinations uses reality-based statements while acknowledging the client’s feelings and maintaining rapport. This response sets a clear boundary that the nurse does not share the perceptual disturbance, yet validates the emotional experience, which can reduce anxiety and support safety. Telling the client the voices “aren’t real” can feel confrontational and may escalate defensiveness or distress. Asking leading or accusatory questions about medication or “again” shifts focus away from assessment of distress and coping and risks shutting down communication.

Question 44

The client with chronic HF tells the nurse, “I get so scared at night; I wake up and feel like I can hardly breathe.” Which is the nurse’s best response?

Accepted Answer

Answer reason:  Therapeutic communication prioritizes open-ended assessment and validation to gather needed data and reduce anxiety before giving teaching or conclusions. This response explores frequency, severity, and coping, which helps determine patterns consistent with heart failure symptoms (e.g., nocturnal dyspnea) and guides safe follow-up actions. Labeling the condition prematurely can shut down communication and misses the client’s expressed fear. Suggesting nightmares or sodium intake without assessment is speculative and can minimize or misattribute potentially serious cardiopulmonary symptoms.

Question 45

The client diagnosed with ESRD states to the nurse, “I don’t think I want to be on dialysis anymore; it’s just too painful for me.” What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: “You feel that dialysis is painful for you. Tell me more about that.” Therapeutic communication prioritizes empathy, reflection, and open-ended exploration to understand the client’s concerns before offering teaching or persuasion. This response validates the client’s feelings and invites elaboration, which helps assess the source of pain (e.g., access discomfort, cramping, anxiety) and readiness for decision-making. “Why” questions can sound accusatory and may shut down communication, even when information-seeking is intended. Minimizing the experience or using fear-based statements is non-therapeutic and can erode trust and autonomy in a high-stakes ESRD decision.

Question 46

The client is informed that he will require a right orchiectomy as part of his treatment of testicular cancer. The client asks the nurse if he will be infertile after this procedure. Which response by the nurse is best?

Accepted Answer

Answer reason:  Fertility after orchiectomy for testicular cancer can be affected by baseline sperm quality and by additional treatments such as chemotherapy or radiation, so the safest nursing response addresses preservation options rather than giving false reassurance or absolute statements. This response is therapeutic and future-oriented, prompting an important discussion and facilitating timely sperm banking before further therapy. It avoids guaranteeing infertility or normal fertility, both of which may be inaccurate for an individual patient. It also supports client autonomy by encouraging shared decision-making with the provider.

Question 47

Two days after hospital discharge, the nurse is assessing the mother and her newborn twins in their home. Which statement or question made by the nurse best demonstrates empathy?

Accepted Answer

Answer reason:  Empathy in therapeutic communication is shown by inviting the client to express their feelings and experience in their own words without judging or assuming. This open-ended question centers the mother’s perspective and supports exploration of emotions during a high-risk adjustment period postpartum. Option A prematurely reassures and normalizes, which can shut down further sharing. Option B is an assumption and shifts focus to the nurse’s viewpoint, and option D is task-focused problem solving rather than emotional attunement.

Question 48

The nurse is caring for the newborn who has a cleft lip and palate- Despite the HCP explaining to the parents the surgical treatment plan and expected good results, the mother refuses to see or hold her baby. What nursing intervention is needed at this time?

Accepted Answer

Answer reason: The priority is supporting parental coping and facilitating attachment through therapeutic communication after an unexpected newborn condition. Allowing the mother to verbalize shock, grief, guilt, or fear helps normalize the reaction, reduces anxiety, and opens the door to gradual involvement in care. Pressuring her with statements about the infant’s need or simply repeating medical information can increase defensiveness and does not address the emotional barrier to bonding. Validating and exploring feelings is the safest, most effective first nursing response while continuing to offer opportunities to see and touch the infant when the mother is ready.

Question 49

The client who recently emigrated from Iran is on the mental health unit and has been placed in seclusion. The nurse assesses that the client is now calm and ready to be assimilated back into the mental health milieu. Which action by the nurse demonstrates cultural insensitivity?

Accepted Answer

Answer reason: In parts of the Middle East, including Iran, the thumbs-up gesture may be perceived as offensive rather than encouraging, risking escalation or loss of trust after seclusion. The other actions are generally culturally supportive or neutral (e.g., offering tea as hospitality, offering a religious text if the client desires it). The priority is to use respectful, culturally congruent communication that promotes rapport and safe reintegration into the milieu.

Question 50

The nurse is evaluating the client with paranoid schizophrenia who reports hearing a voice say, “Do not remove your hat because they will be able to read your mind.” Which response by the nurse is therapeutic?

Accepted Answer

Answer reason:  Therapeutic communication with psychosis focuses on acknowledging feelings while avoiding reinforcing or arguing with delusions and hallucinations. This response validates the client’s emotional experience (fear) and helps build rapport without confirming that mind-reading is real. Options that probe details (who/why) can intensify paranoia and further entrench the delusional framework. Directly challenging the belief can increase defensiveness and reduce trust, making engagement and safety planning harder.

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