Comprehensive exams for Mental Health Q 131
The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is:
A. “You’re attractive, but I’m not interested.”
B. “You wouldn’t be the first that I will see naked.”
C. “I will report you to the guard if you don’t control yourself.”
D. “I only need access to your arm. Putting up your sleeve is fine.”
Correct Answer: D. “I only need access to your arm. Putting up your sleeve is fine.”
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on their statement, prompting patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case; as impartial observers, nurses can more easily pick out the topics to focus on.
Option A: Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that might pose a problem for them. Observing that they look tired may prompt patients to explain why they haven’t been getting much sleep lately; making an observation that they haven’t been eating much may lead to the discovery of a new symptom.
Option B: These responses are not therapeutic because they are challenging and rejecting. It’s frequently useful for nurses to summarize what patients have said after the fact. This demonstrates to patients that the nurse was listening and allows the nurse to document conversations. Ending a summary with a phrase like “Does that sound correct?” gives patients explicit permission to make corrections if they’re necessary.
Option C: Threatening the client is not therapeutic. Nurses should only apply this technique after they have established trust. It can be vital to the care of patients to disagree with them, present them with reality, or challenge their assumptions. Confrontation, when used correctly, can help patients break destructive routines or understand the state of their situation.