Question 1

The client experiencing paranoid delusions tells the nurse that “the foreigner who lives next to me wants to kill me.” Which nursing response is most therapeutic to assist the client experiencing paranoid delusions?

Accepted Answer

Answer reason:  Therapeutic communication with delusions focuses on acknowledging the client’s experience and feelings without validating the delusional content. This response reflects and restates the client’s belief, which conveys empathy, encourages further sharing, and helps the nurse assess intensity and risk while maintaining reality-based boundaries. Directly challenging the belief can increase mistrust and defensiveness, worsening paranoia. Probing for “evidence” can inadvertently reinforce the delusion by implying it is reasonable to justify, whereas reflection keeps the focus on the client’s perception and safety assessment.

Question 2

The client experiencing paranoid delusions asks the nurse to turn off the television, stating, “It controls my thoughts.” Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: The principle is to reduce anxiety and maintain safety while avoiding arguing about or reinforcing a fixed false belief. Turning off the TV is a harmless, reality-neutral action that can immediately decrease distress and support engagement without validating the delusional content. Refusing solely to avoid “supporting” the delusion is unnecessary when the request is benign and may escalate paranoia and agitation. The therapeutic focus is calming, building trust, and redirecting to feelings and coping strategies rather than power struggles or confrontation.

Question 3

The nurse engages the older adult client by describing the weather as “raining cats and dogs.” The client looks bewildered and shows concern for the “animals.” Which response by the nurse is most therapeutic?

Accepted Answer

Answer reason: Therapeutic communication uses clear, concrete language and clarifies misunderstandings to reduce anxiety and promote reality-based understanding. The client interpreted an idiom literally, indicating concrete thinking, so the most helpful nursing response is to explain the meaning in simple terms. This directly addresses the client’s confusion without reinforcing the literal interpretation. Providing reassurance about “animals” may unintentionally validate the misunderstanding rather than clarify it, and staff notification or documentation are not the immediate therapeutic response to the client’s distress.

Question 4

The experienced nurse is orienting a new nurse on a mental health unit. Which intervention should the nurse suggest when attempting to establish a therapeutic relationship with the newly admitted client diagnosed with major depressive disorder?

Accepted Answer

Answer reason: Clients with major depressive disorder often have low energy, psychomotor slowing, and difficulty initiating conversation, so pressured interaction can increase withdrawal. Therapeutic use of self (being physically present, accepting, and nonjudgmental) builds trust while allowing the client to engage at a tolerable pace. Quiet presence communicates availability and safety without demanding performance, which is especially important early in admission. In contrast, group activities or complex planning may be overwhelming initially and can feel like the nurse is avoiding the client’s emotional state rather than connecting with it.

Question 5

The nurse is interacting with the client who abuses methamphetamine- The client states, “I don’t plan to quit meth. I can work for days when I’m high.” Which is the best response by the nurse?

Accepted Answer

Answer reason: “You say you don’t plan to quit. Do you think using drugs helps you?” Therapeutic communication uses reflection and open-ended questions to explore ambivalence and promote insight without judgment. This response acknowledges the client’s stated position and invites the client to evaluate the costs/benefits of use, which aligns with motivational interviewing principles for substance use. In contrast, labeling the client as “in denial” is confrontational and can increase resistance, while agreeing with the statement reinforces maladaptive behavior. Warning about exhaustion is a closed, moralizing statement that shifts focus to a lecture rather than facilitating self-assessment and readiness for change.

Question 6

The mother of a child diagnosed with hypopituitarism states to the nurse that she feels guilty because she should have recognized this disorder. What is the best response by the nurse about children with hypopituitarism?

Accepted Answer

Answer reason: Growth hormone deficiency typically becomes evident after birth when linear growth slows, rather than causing abnormal fetal growth. Because intrauterine growth is largely driven by maternal/placental factors and insulin-like growth factors, many affected infants are born with a normal weight and length for gestational age. This supports reassuring the parent that there may have been no early outward signs to recognize at birth, reducing inappropriate guilt. Options suggesting consistent LGA/SGA at birth or obvious early postnatal signs overstate the usual presentation and are less accurate for typical hypopituitarism recognition.

Question 7

The nurse is aware that parents of a child with Reye’s syndrome need a great deal of emotional support. What is the most important intervention for the nurse to include in the plan of care?

Accepted Answer

Answer reason: Reye’s syndrome can deteriorate rapidly with neurologic compromise, so parents commonly experience fear, confusion, and difficulty processing one-time explanations. Ongoing clarification of therapies and reinforcement of what the team is doing helps build trust, supports coping, and improves participation in care decisions. In contrast, minimizing feelings (“don’t overreact”) invalidates distress and can worsen anxiety, while setting limits on aggression is important but is not the primary supportive intervention.

Question 8

A female client with bulimia nervosa tells a nurse her major problem is eating too much food in a short period of time and then vomiting. Which shortterm goal is the most important?

Accepted Answer

Answer reason: Bulimia is driven by intense anxiety, shame, and distorted beliefs around eating and control, so the most urgent short-term nursing goal is to open therapeutic communication that reduces secrecy and supports insight. Getting the client to name fears and concerns is an achievable immediate target that builds rapport and creates a foundation for safer eating behaviors. Setting a specific “amount to eat without purging” is premature and can become another focus for control or bargaining rather than addressing triggers. Arranging therapy is important, but it is a longer-term, system-level action rather than the most immediate client-centered short-term goal in the moment.

Question 9

A client on your unit says the Mafia has a contract out on him. He refuses to leave his semiprivate room and insists on frisking his roommate before allowing him to enter. Which action should the nurse take first?

Accepted Answer

Answer reason: Therapeutic communication starts with validating the emotion without validating the delusion, which helps de-escalate anxiety and maintain a trusting nurse–client relationship. This response addresses the immediate distress driving the unsafe request to search another person while preserving the client’s dignity and boundaries. Room changes (for either person) may be considered later for milieu management, but they do not address the immediate need for calming and reality-based support. Forcing the client out of the room is coercive, increases agitation, and raises safety risk for the client and others.

Question 10

A schizophrenic client tells his primary nurse that he’s scheduled to meet the King of Samoa at a special time, making it impossible for the client to leave his room for dinner. Which response by the nurse is most appropriate?

Accepted Answer

Answer reason: “It’s mealtime. Let’s go so you can eat.” Therapeutic communication with delusions focuses on reality-based, concrete statements without validating the delusional content. This response gently redirects the client to a normal routine and meets a basic physiological need while avoiding argument about the belief. It preserves rapport by not challenging or mocking the delusion, which can increase agitation or mistrust. In contrast, claiming the nurse also spoke with the “King of Samoa” reinforces the delusion and is nontherapeutic, while the other options are authoritarian or shaming.

Question 11

As a nurse approaches the nursing station, a client with the diagnosis of delusional disorder raises his voice and says, “You’re following me. What do you want?” What is the best response by the nurse?

Accepted Answer

Answer reason: “I’m sorry if I frightened you. I was returning to the nursing station after going out for lunch.” Therapeutic communication with delusional or suspicious clients focuses on conveying safety, acknowledging feelings, and presenting simple reality-based information without arguing about the belief. This response de-escalates by offering an apology for the client’s emotional experience and briefly explaining the nurse’s actions in a neutral, factual way. Directly confronting the delusion can increase defensiveness and mistrust, escalating agitation. Threatening seclusion is premature and may worsen paranoia unless there is imminent danger and less restrictive measures have failed.

Question 12

A female client with chronic obstructive pulmonary disease (COPD) tells a nurse, “I no longer have enough energy to make love to my husband.” What is the most appropriate nursing intervention?

Accepted Answer

Answer reason: Nursing care should address sexual health concerns by offering practical, individualized strategies that reduce symptom burden and conserve energy. With COPD, fatigue and dyspnea commonly limit intimacy, so teaching measures such as timing activity when rested, using comfortable positions, pacing, and using bronchodilators/oxygen as prescribed can improve tolerance and confidence. This is a direct, within-scope intervention that supports function and coping without unnecessary escalation. Referral to a sex therapist or gynecology may be appropriate later if problems persist or other causes are suspected, but the priority first action is targeted education and problem-solving. Minimizing the concern by simply suggesting discussion with the husband does not address the physiologic limitation or provide actionable support.

Question 13

A 50-year-old male client who had a myocardial infarction 8 weeks ago tells a nurse, “My wife wants to make love, but I don’t think I can. I’m worried that it might kill me.” What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Therapeutic communication begins with exploring the client’s concerns to reduce anxiety and identify specific fears and misconceptions. An open-ended invitation encourages expression, builds rapport, and allows assessment of readiness for education about resuming sexual activity post-MI. Immediately changing the plan of care or deferring to the provider is premature when the priority is addressing anxiety and clarifying the client’s understanding. Telling him what to say to his wife is nontherapeutic and dismisses the client’s fear rather than helping him process it.

Question 14

A female client taking antidepressant medication complains to the nurse that she has a decreased desire for sex, which is causing significant marital stress. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Sexual dysfunction is a common adverse effect of many antidepressants and should be assessed and managed without prompting abrupt self-discontinuation. The safest nursing response is to facilitate appropriate medical follow-up so the prescriber can evaluate dose adjustment, switching agents, or adding treatments while maintaining therapeutic control of depression. This option supports collaboration and promotes adherence while addressing a distressing side effect that impacts relationships. In contrast, directing the client to solve it alone or implying blame toward the spouse is nontherapeutic and does not address the medication-related cause.

Question 15

A mother brings her 14-year-old son to the psychiatric crisis room. The client’s mother states, “He’s always dressing in female clothing. There must be something wrong with him.” Which response from the nurse would be most appropriate?

Accepted Answer

Answer reason: “I know you’re upset. Would you like to talk?” Therapeutic communication prioritizes empathy, reflection of feelings, and open-ended invitation to explore concerns without judgment. This response acknowledges the mother’s distress and creates space to assess her understanding, fears, and the adolescent’s safety needs. Options that judge or align with the mother’s bias increase stigma and can harm rapport and trust, while the task-focused response deflects the emotional concern and does not address the immediate psychosocial issue. In crisis settings, validating emotions and engaging the caregiver supports de-escalation and more effective assessment and planning.

Question 16

A new graduate nurse expresses concern to the nurse-manager about working with clients who want to discuss sexual problems. What is the best response by the nurse-manager?

Accepted Answer

Answer reason:  Therapeutic communication begins with an open-ended, nonjudgmental assessment to clarify feelings, knowledge gaps, and specific barriers. This response invites the new nurse to elaborate, allowing the manager to identify whether the issue is discomfort, lack of skills, boundary concerns, or need for education/supervision. Dismissive reassurance minimizes the concern and discourages help-seeking, while automatic referral avoids developing the nurse’s competency in an expected area of patient care. The statement about being a sex counselor is inaccurate and promotes practice outside appropriate training and role expectations.

Question 17

A client asks the nurse, “Why does it matter if I talk to my peers in group therapy?” What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  Group therapy is built on mutual support, shared experiences, and interpersonal learning, which helps clients reduce isolation and practice healthier coping skills. This response clearly explains the therapeutic value of peer interaction in a nonjudgmental, encouraging way that promotes engagement. Option A is confrontational and implies blame, increasing defensiveness and reducing willingness to participate. Option D narrows group therapy to “venting,” which can be countertherapeutic if it reinforces complaints without fostering insight, feedback, and skill-building.

Question 18

The preoperative client verbalizes fear of postoperative pain. Which nursing action would be best?

Accepted Answer

Answer reason: Therapeutic communication prioritizes exploring the client’s feelings and perceptions to reduce anxiety and build trust before moving into teaching or problem-solving. Inviting the client to verbalize concerns helps the nurse identify specific fears (e.g., loss of control, prior pain experiences, misconceptions) and tailor both education and the pain-management plan accordingly. Education about pain and analgesics can be appropriate after the nurse assesses the client’s concerns and readiness to learn, but it is not the best initial response to expressed fear. Diversional activities may provide temporary relief but can bypass the underlying anxiety and do not assess the client’s needs.

Question 19

The male client newly diagnosed with stage II prostate cancer states to the nurse, “With this diagnosis, I want the doctor to write a Do not. Resuscitate order.” Which is the nurse’s best initial action?

Accepted Answer

Answer reason: A new cancer diagnosis can trigger fear, anxiety, and catastrophic thinking; the nurse’s first priority is to assess the client’s understanding and emotional state using therapeutic communication. Exploring feelings helps determine whether the request reflects informed, stable preferences versus an acute distress reaction, and it opens the door to clarify what a DNR does and does not mean. Contacting the provider may be needed later to formalize orders, but it is not the best initial step before assessing readiness and ensuring informed decision-making. Referring to chaplaincy or focusing on others’ experiences is not as directly supportive or assessment-focused as exploring the client’s feelings first.

Question 20

After falling at home, the 84-year-old client is brought to the ED by the client’s adult child. Upon assessing the client, the nurse discovers that the client is aphasic and unable to answer any of the nurse’s questions. Which intervention should be taken by the nurse initially?

Accepted Answer

Answer reason: Yes/no questioning with a simple nonverbal response is quick, low-effort, and can be used immediately in the ED without additional equipment. A writing board may fail if the client also has impaired motor control, vision, or literacy after a possible neurologic event, making it less dependable as the first step. Consulting speech therapy is appropriate later, and directing questions to the family risks bypassing the client and may produce incomplete or biased information compared with attempting direct communication first.

Question 21

The mother of a child who had a febrile seizure tells the pediatric clinic nurse, “I am so upset because now my child has epilepsy.” Which statement is the clinic nurse’s best response?

Accepted Answer

Answer reason:  Febrile seizures are provoked seizures associated with fever and, by themselves, do not mean a child has epilepsy (unprovoked recurrent seizures). The priority therapeutic response is to correct the mother’s misunderstanding with clear, reassuring teaching that directly addresses the inaccurate conclusion. The other responses primarily explore feelings or offer resources but do not first correct the incorrect belief that the child now has epilepsy. Providing accurate information reduces anxiety and supports appropriate follow-up and safety planning.

Question 22

The nurse should demonstrate compassion and empathy when communicating news about the death of a client to the family. Which is an example of appropriate communication skills by the nurse during this situation?

Accepted Answer

Answer reason: A brief condolence statement supports the family emotionally and invites further expression if they choose. Minimizing phrases such as “It’s okay” can invalidate feelings, and euphemisms like “at peace now” impose meaning that may not match the family’s beliefs. Technical or abrupt language about resuscitation focuses on tasks rather than the family’s immediate emotional needs and can sound cold.

Question 23

While caring for a terminally ill infant, the nurse asks the mother if she wants the baby to be baptized. The mother becomes upset and asks to speak to the nurse-manager. What is the best response by the nurse-manager?

Accepted Answer

Answer reason: Therapeutic communication in end-of-life care prioritizes client-centered, nonjudgmental exploration of beliefs and preferences, especially when the family is distressed. Allowing the mother to share her spiritual wishes supports autonomy, reduces escalation, and helps identify appropriate resources tailored to her values. Automatically calling the chaplain can feel presumptive and may further invalidate her feelings if her beliefs differ. Explaining the nurse’s religion shifts focus away from the mother, risks boundary issues, and does not address the emotional impact of the interaction.

Question 24

A newly graduated nurse is caring for a client recently diagnosed with dissociative identity disorder. The nurse asks the preceptor about discussing the client’s traumatic childhood with the client. Which advice from the preceptor is best?

Accepted Answer

Answer reason:  Therapeutic communication for dissociative identity disorder prioritizes safety, trust, and a nonjudgmental approach while avoiding interrogation or pressure that can increase anxiety and dissociation. A supportive, listening stance allows the client to share at their own pace and helps prevent re-traumatization. Pressing for specific details can intensify distress and destabilize coping, and challenging the client’s memories is invalidating and can damage rapport. Deferring discussion “to a physician only” is inaccurate and avoids the nurse’s role in providing supportive presence and ongoing assessment.

Question 25

The young adult, diagnosed with hemophilia A, is receiving a monthly scheduled dose of factor VIII cryoprecipitate. The client begins to cry during administration. Which response by the nurse is most appropriate?

Accepted Answer

Answer reason: " Crying during a procedure is a cue for psychosocial distress and calls for therapeutic communication that invites expression of feelings. This response is open-ended, nonjudgmental, and conveys presence, allowing the client to share fear, pain, or other concerns so the nurse can respond appropriately. Option A is leading and can sound accusatory, which may shut down communication. Options B and C focus prematurely on procedural comfort/time and may minimize the emotional experience before assessing what the crying means.

Question 26

The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest “Lou Gehrig”s disease. Which is the nurse’s most appropriate response?

Accepted Answer

Answer reason: " Therapeutic communication during an initial assessment prioritizes exploring the client’s concerns with open-ended, nonjudgmental questions. This response invites the client to describe symptoms, fears, and any prior information prompting the worry, which supports accurate assessment and reduces anxiety through validation. It avoids falsely reassuring or minimizing the concern, which can shut down communication and miss key data. In contrast, deferring with a vague statement about future tests provides less emotional support and does not assess the client’s perception and reasoning in the moment.

Question 27

The client with warts in the labial area is being seen in the clinic. The client is tearful and states to the nurse, “I’m so embarrassed that I let this happen to me.” Which response by the nurse is appropriate?

Accepted Answer

Answer reason: “ I see you are upset. Having labial warts is quite common. Let’s talk more about it.” This uses therapeutic communication by acknowledging the client’s feelings and inviting further discussion, which helps reduce shame and supports coping. Normalizing the condition can decrease stigma without dismissing the client’s emotional response. The other choices rely on reassurance and minimization (e.g., telling the client not to be embarrassed or that there’s no need for tears), which can invalidate feelings and shut down communication. An open-ended invitation to talk promotes trust, assessment of concerns (e.g., transmission, treatment, partner notification), and patient-centered education.

Question 28

The client tells the nurse, "Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby." Which is the most accurate response from the nurse?

Accepted Answer

Answer reason: "Feeling differently from day to day is normal. How do you feel today?" Therapeutic communication validates the client’s feelings and uses an open-ended question to encourage further expression. Ambivalence during pregnancy can be a normal adjustment response, so normalization can reduce anxiety and shame while keeping the focus on the client’s current emotional state. This approach invites assessment of mood and coping without judging or dismissing concerns. In contrast, telling the client to “be optimistic” or shifting to the spouse’s feelings blocks communication and does not address the client’s needs.

Question 29

The client, who is Chinese American and pregnant, is receiving nutritional counseling about the need for increased amounts of calcium in her diet. Which response by the nurse is most helpful when the client states she does not consume any dairy products?

Accepted Answer

Answer reason:  Therapeutic communication begins with assessing the client’s beliefs, preferences, and cultural practices before giving prescriptive advice. This open-ended, culturally sensitive question builds rapport and identifies why the client avoids dairy (e.g., intolerance, taste, cultural norms), which then guides individualized, realistic calcium planning. It is more helpful than immediately directing a specific regimen, which may be impractical or culturally unacceptable. Some listed alternatives may also be questionable or incomplete (e.g., herbal tea claims), reinforcing why assessment should come first.

Question 30

The nurse is unavoidably late in changing the dressing on the client’s leg. The client reacts by becoming verbally aggressive and telling the nurse, “None of you can be trusted. You all just make promises you never intend to keep.” Which should be the nurse’s initial action?

Accepted Answer

Answer reason: Therapeutic communication prioritizes acknowledging the patient’s feelings and taking appropriate responsibility to rebuild trust and reduce escalation. A sincere apology validates the client’s perception of being let down and helps de-escalate anger, which supports continued care (dressing change) without power struggles. Asking “why” and labeling the response as “overreacting” is nontherapeutic and likely to intensify defensiveness. Calling for other staff or leaving the room can be appropriate if there is imminent risk, but the initial response to verbal aggression without stated threat is to engage calmly and repair the relationship.

Question 31

The nurse is caring for the client who states, “Lately I’m getting forgetful about things. I’m so afraid I’m getting Alzheimer’s disease.” Which response by the nurse is most therapeutic?

Accepted Answer

Answer reason:  Therapeutic communication validates the client’s feelings and invites further exploration without giving false reassurance or dismissing the concern. This response normalizes mild forgetfulness while opening the door to assess the client’s anxiety, functional impact, and specific symptoms. It uses an open-ended, client-centered approach that encourages expression and supports coping. In contrast, minimizing or diagnosing (e.g., saying it isn’t Alzheimer’s) can shut down communication and overlooks the need for assessment, and self-disclosure shifts focus away from the client.

Question 32

The nurse is caring for the client experiencing paranoid delusions. While the nurse is attempting to explain the need for obtaining laboratory blood work, the client shouts, “You all just want to drain my blood. Get away from me!” Which nursing response is most therapeutic?

Accepted Answer

Answer reason:  The therapeutic approach to paranoid delusions is to acknowledge the client’s feelings and provide support without validating or arguing about the delusional belief. This response reflects empathy and helps reduce anxiety, which can improve engagement and trust. Asking for “what makes you think” can feel like interrogation and may escalate suspicion. Reassurance or leaving without addressing fear can be experienced as dismissive and does not help the client feel understood or safe in the moment.

Question 33

The nurse is caring for a victim of sexual assault brought to the ED by a roommate. How should the nurse respond when the client begins to angrily insist upon reporting the details of the assault?

Accepted Answer

Answer reason: Allowing the client to verbalize emotions with a calm, nonjudgmental presence supports coping, builds trust, and avoids shutting down disclosure. Trying to redirect to tasks or focusing on “calming down” techniques can feel minimizing and may increase distress or inhibit needed expression. Involving the roommate is not essential to the immediate therapeutic response and may interfere with privacy and the client’s sense of control.

Question 34

The client’s home was destroyed by a major flood. The client is attending a support group and says, “I will rebuild my home as good as new and be back in it in a few months.” What should be the nurse’s initial response?

Accepted Answer

Answer reason:  Therapeutic communication starts with exploring the client’s perception and encouraging elaboration before judging, advising, or redirecting. This response uses an open-ended, information-seeking approach to assess the realism of the client’s expectations and their coping/adjustment after disaster. It also conveys interest and supports problem-solving without minimizing feelings or introducing new anxiety. In contrast, praising or labeling the plan as “ambitious” can shut down discussion, and focusing on future flooding prematurely shifts to fear-based thinking.

Question 35

A 32-year-old client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). The preliminary report of biopsies done on his facial lesions indicates Kaposi’s sarcoma. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Therapeutic communication prioritizes open-ended exploration of the client’s perceptions and emotions, especially when appearance changes can affect self-esteem, stigma, and coping. This response invites the client to express concerns and guides the nurse in assessing anxiety, body-image disturbance, and support needs without assuming what the client feels. Providing factual statements about prevalence can sound minimizing, and ignoring the lesions is nontherapeutic and invalidating. Discussing biopsy results may be appropriate when finalized and within role, but the most immediate, supportive nursing response is to assess and validate feelings first.

Question 36

A 15-year-old client needs a nasogastric tube inserted because of peritonitis caused by a ruptured appendix. The client is afraid that the procedure will hurt. Which statement by the nurse is most appropriate to help decrease the client’s anxiety?

Accepted Answer

Answer reason:  Anxiety is reduced best by providing honest, developmentally appropriate anticipatory guidance that sets realistic expectations. This statement prepares the adolescent for the likely sensations (pressure/discomfort) and provides a time-limited frame, which supports coping and builds trust. In contrast, promising it “won’t hurt” is false reassurance and can increase fear and distrust if discomfort occurs. The other responses either minimize feelings or are judgmental, which can worsen anxiety and impair cooperation during the procedure.

Question 37

A child has been diagnosed with cancer and is scheduled for chemotherapy. The parents ask the nurse how they should explain the side effect of hair loss to the child. What is the best response by the nurse?

Accepted Answer

Answer reason: Children and families cope better when they receive honest, developmentally appropriate information that includes reassurance about what to expect and that the change is temporary. This response sets realistic expectations and supports hope without minimizing the impact of alopecia, which helps reduce anxiety and improves adjustment during treatment. Discussing wigs only after hair loss delays preparation and can increase distress once changes occur. Focusing on more severe future hair loss or styling “camouflage” is either unnecessary, potentially frightening, or shifts away from the core concern of explaining the side effect clearly.

Question 38

A female being treated for infertility confides to the nurse that she hasn’t told her partner she has been treated for a sexually transmitted disease in the past. What is the best response by the nurse?

Accepted Answer

Answer reason: Therapeutic communication prioritizes open-ended, nonjudgmental questions that help the client explore feelings, barriers, and readiness for disclosure. This response invites the patient to elaborate on fears (e.g., rejection, conflict, stigma) and supports problem-solving while maintaining a supportive stance. In contrast, options that challenge or shame the client can increase defensiveness and shut down communication. The most helpful nursing response is to assess the client’s concerns first, then provide education and support for safe, honest communication as appropriate.

Question 39

A 17-year-old female who enjoys playing ball with boys and is most comfortable in jeans tells her mother she doesn’t want to go to the prom if she has to wear a frilly dress. Her mother asks, “What should I do with my daughter?” What is the best response by the nurse?

Accepted Answer

Answer reason: Therapeutic communication focuses on exploring the family’s feelings and concerns without judging the adolescent’s gender expression or implying pathology. Inviting the mother to describe her fears uses an open-ended, empathetic approach that can uncover specific worries (e.g., safety, peer reactions) and guides appropriate support. Dismissing the concern (“she’ll grow out of it”) minimizes the mother and can shut down further discussion. Trying to “fix” the teen’s clothing choices or directing a specific action for prom is nontherapeutic and undermines adolescent autonomy.

Question 40

A client has learned that his gay roommate has tested positive for human immunodeficiency virus (HIV). The client asks the nurse about moving to another room on the psychiatric unit because the client doesn’t feel “safe” now. What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Therapeutic communication starts with assessment of the client’s beliefs and emotions before taking action. Exploring what “unsafe” means allows the nurse to identify misconceptions about HIV transmission and address stigma without violating the roommate’s privacy or reinforcing discrimination. Room changes based solely on HIV status are not clinically indicated because HIV is not spread through casual contact in a shared room. Immediate relocation of either person would validate the fear and can worsen unit dynamics, whereas focused exploration supports education and coping.

Question 41

When the nurse hands the client a second dose of oxycodone/acetaminophen for incisional pain, the client says, “This medication makes me feel sick.” Which statement is the most appropriate initial response by the nurse?

Accepted Answer

Answer reason:  Therapeutic communication starts with assessing the client’s meaning and specific symptoms before offering solutions or changing the plan of care. This open-ended question clarifies whether “sick” means nausea, dizziness, pruritus, anxiety, or another adverse effect, which guides safe next actions (e.g., antiemetic, dose adjustment, alternative analgesic). Immediately calling the provider or administering an additional medication skips assessment and could mask a serious reaction. One distractor also contains inaccurate information about the medication’s ingredients, underscoring why clarification is the safest first step.

Question 42

The nurse is completing the final visit with the client being discharged from home-care services. Each time that the nurse attempts to leave, the client offers a new subject and attempts to delay the nurse’s departure Which is the best action by the nurse?

Accepted Answer

Answer reason: Therapeutic nurse-client relationships require clear boundaries and appropriate termination to support patient autonomy and prevent dependence. The client’s repeated topic-shifting suggests anxiety about ending services, which is best managed by acknowledging termination, setting limits, and inviting the client to express feelings and summarize progress. This approach maintains professionalism while still being empathetic and client-centered. Abruptly ending the visit is non-therapeutic, and arranging extra visits or social meetings blurs boundaries and reinforces avoidance of termination.

Question 43

The nurse is preparing a campaign for seventh- and eighth-grade teachers. The purpose of the campaign is to decrease and subsequently eliminate bullying at school. Which strategy should the nurse utilize to most effectively present this information to the teachers?

Accepted Answer

Answer reason: Case-based learning mirrors actual bullying scenarios, promotes critical thinking, and lets participants practice consistent language, reporting steps, and boundary-setting in a safe setting. Facilitated discussion also surfaces common barriers (e.g., bystander dynamics, confidentiality, fear of retaliation) and aligns staff on a shared approach, which is essential for school-wide culture change. Compared with a lecture, case discussion is more likely to translate into actionable interventions and consistent implementation across classrooms.

Question 44

The nurse is planning prenatal classes for pregnant adolescents intending to keep their babies. Which teaching strategy would be most effective for the adolescents?

Accepted Answer

Answer reason: Group prenatal classes allow participants to share experiences, practice skills, and ask questions in a supportive setting, which increases engagement and retention. Including mothers in one-to-one sessions can undermine adolescent independence and may reduce honest discussion of sensitive topics. Open sessions with “anyone” present can decrease privacy and willingness to participate, and posters alone are passive education and are less effective for behavior change and skills acquisition.

Question 45

The 94-year-old client, who has been on chronic hemodialysis for 8 years, states to the dialysis nurse upon arrival, “I no longer want to continue dialysis. I have had a good life, and now I am ready to let go” Which intervention by the nurse is best?

Accepted Answer

Answer reason:  Therapeutic communication begins with clarification and reflection to validate what was heard and invite the client to elaborate in a nonjudgmental way. This response helps assess decisional capacity, understanding of consequences, and whether the statement reflects depression, hopelessness, uncontrolled symptoms, or a consistent end-of-life preference. The “why” question can sound accusatory and may shut down communication, whereas reflection keeps the discussion open and client-centered. Starting dialysis despite the stated refusal disregards client autonomy, and immediate psychiatric consult is premature without first assessing for actual suicidal intent and exploring the meaning of the statement.

Question 46

The nurse is instructing parents of Mexican origin about administering their toddler’s oral medication. What method is best to ensure that the toddler will get the prescribed amount of medicine at the appropriate times?

Accepted Answer

Answer reason: Teach-back/return-demonstration is the most reliable way to verify caregiver understanding and ability to measure and time doses correctly before leaving the hospital. Observing the parent administer (or simulate administering) the medication allows the nurse to identify errors in dose measurement (e.g., wrong device, misreading mL) and timing and correct them immediately. An interpreter can improve comprehension but does not confirm the parent can accurately perform the skill. Written instructions alone are often insufficient, especially when health literacy and language differences may affect correct dosing and scheduling.

Question 47

The nurse discusses organ donation with a family whose loved one has suddenly passed. Common courtesy and sensitivity to the family's grief are important. Which action facilitates the family's option of organ donation?

Accepted Answer

Answer reason: Grief conversations require therapeutic communication that preserves dignity, allows questions, and supports informed, unpressured decision-making. Privacy reduces distractions, protects confidentiality, and helps the family process emotions and information clearly, which supports consideration of donation. Telling the family the decision is not theirs violates client rights and informed consent principles and is coercive. Approaching “immediately” or delaying acknowledgment of death until after forms are signed can be perceived as insensitive and may erode trust, decreasing willingness to consider donation.

Question 48

The nurse is getting up supplies to complete a dressing change at 2000 hours on the client's stump following a right leg BKA. The client looks away and angrily says, "I don't want to look at that thing. Can't you come back later?" Which is the nurse's best action?

Accepted Answer

Answer reason: Restate, "You don't want to look at your leg?" and allow time for a response. Therapeutic communication prioritizes reflecting and exploring the client’s feelings to promote expression and coping, especially after a new amputation with altered body image. Reflection validates the emotion and invites the client to elaborate without judgment, which can reduce defensiveness and build rapport. Proceeding solely because of the schedule ignores psychosocial distress and can escalate anger and resistance, risking nonadherence. “Why” questions often feel accusatory and can shut down communication rather than encourage sharing. Delaying the care without first addressing the underlying emotion misses an immediate opportunity to support adaptation and may not resolve the refusal.

Question 49

A prenatal client tells the nurse she can’t believe she has such mixed feelings about being pregnant. She tried for 10 years to become pregnant and now she feels guilty for her conflicting reactions. Which response is best?

Accepted Answer

Answer reason:  Normalizing and validating feelings is a core therapeutic communication technique in prenatal care, because mixed emotions during pregnancy are common even when the pregnancy is desired. This response reduces guilt and anxiety by reframing ambivalence as an expected adjustment reaction rather than a sign that something is “wrong.” It also keeps the conversation open so the nurse can further assess coping and support systems. Referring immediately to a midwife or counselor implies pathology or abnormality without first providing support and assessment, and claiming it occurs only in those with infertility is inaccurate and isolating.

Question 50

The client asks the nurse, “My doctor just told me that atherosclerosis is why my chest hurts when I walk real fast. What does that mean?” Which statement is the nurse's best response?

Accepted Answer

Answer reason:  Atherosclerosis causes plaque to narrow coronary arteries, limiting blood flow and oxygen delivery during increased demand such as fast walking, which produces exertional chest pain (stable angina). This response uses clear, patient-friendly language to explain the pathophysiology and directly links it to the symptom the client describes. Option A is incomplete and less understandable for patient teaching because it doesn’t explain plaque or the oxygen supply problem. Option B reflects feelings but does not answer the client’s request for an explanation, and option C incorrectly attributes symptoms to valvular disease.

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