Author Question: The patient says, My marriage is just great. My spouse and I usually agree on everything. The nurse ... (Read 37 times)

K@ · **on:** Jul 19, 2018

The patient says, My marriage is just great. My spouse and I usually agree on everything. The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. What conclusion can the nurse draw? The patient's communication is:

a. clear.
b. mixed.
c. precise.
d. inadequate.

Question 2

A patient with paranoid schizophrenia tells the nurse, The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say. Which response by the nurse would be most therapeutic?

a. Let's talk about something other than the CIA.
b. It sounds like you're concerned about your privacy.
c. The CIA is prohibited from operating in health care facilities.
d. You have lost touch with reality, which is a symptom of your illness.

millet · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: B
Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. The patient's verbal message that all is well in the relationship is modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.

Answer to Question 2

ANS: B
It is important not to challenge the patient's beliefs, even if they are unrealistic. Challenging undermines the patient's trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the patient's message conveys. The correct response uses the therapeutic technique of reflection. The other comments are nontherapeutic. Asking to talk about something other than the concern at hand is changing the subject. Saying that the CIA is prohibited from operating in health care facilities gives false reassurance. Stating that the patient has lost touch with reality is truthful but uncompassionate.