A nurse has for the past 4 weeks been working with a psychotic ...

[jilianpiloj]

A nurse has for the past 4 weeks been working with a psychotic patient who has been mute and very withdrawn. The patient suddenly encroaches on the nurse's personal space by touching inappropriately.
 
  What is the most therapeutic response by the nurse to address this behavior?
  a. Ignore it this time because the patient is, at last, responding.
  b. Firmly communicate acceptable boundaries to the patient.
  c. Gently touch the patient's head and then observe the reaction.
  d. Smile while telling the patient that people don't like being touched like that.

Question 2

A patient indicates that he is about to share information about his illness that is shocking and embarrassing. Which nursing intervention has priority in this situation in facilitating the communication process?
 
  a. Reassuring the patient that talking will be therapeutic
  b. Assuring the patient the information will be kept confidential
  c. Responding to the patient's information in an accepting manner
  d. Providing the patient with a private place for the discussion to occur

[lcapri7]

Answer to Question 1

ANS: B
The therapeutic response is to clearly communicate appropriate boundaries. There are times when patients misinterpret the nurse's nurturing as an invitation to an intimate relationship. In these instances, boundaries must be firmly, but neutrally, explained. The behavior should not be ignored since doing so may well result in the patient repeating the behavior with others, perhaps with disastrous results. Touch is often misinterpreted by psychotic patients and in this case has no therapeutic value. Nonverbal communication should always be congruent so as to avoid confusing the patient.

Answer to Question 2

ANS: C
Responding to the patient's information in a nonjudgmental, accepting manner will encour-age continued therapeutic communication. The remaining options, although appropriate, will not have the same generalized affect on the communication process as the correct option.

[jilianpiloj]

TY

[lcapri7]

Happy to Help