2022, Module 3 Exam_ HESI VN Questions And Answers (updated) 95%

7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 1 1 / 1 pts The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother scolded her for picking the neighbors’ flowers. Which defense mechanism used by the child does the nurse identify in the mother’s report? Projection Sublimation Correct! Displacement Identification Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a substitute person or object that is less threatening to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse, such as that which occurs in blaming or scapegoating, to someone else. Sublimation is the act of rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's. Test-Taking Strategy: Use the process of elimination and knowledge regarding the subject, defense mechanisms. Focusing on the data in the question and the child’s behavior will direct you to the correct option. Review these defense mechanisms if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 2 1 / 1 pts 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A client says to the nurse, “I’ve been following my diet and taking my medication. What else do you want to talk about today?” Which response would be most helpful during the working phase of the therapeutic alliance? “Sounds fine to me. Let’s meet again in 6 months.” “I don’t believe that you have been following your diet because you haven’t lost any weight.” “Well, you’ve talked about diet in your terms, but perhaps I should test you on specific things.” “Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?” Correct! Rationale: Although suggestion or overt giving of advice is sometimes nontherapeutic, these strategies are therapeutic when used in the working phase, because in this situation they will increase the client’s perception of all available options in the treatment plan. Answering “Sounds fine to me. Let’s meet again in 6 months” stops the communication process. Stating to the client that he or she has not lost any weight implies disbelief and does not explore the reasons for the client’s failure to lose weight. “Testing” challenges the client and is nontherapeutic. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Noting the words “working phase” in the question will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 3 1 / 1 pts As the nurse prepares to interview a client being admitted to the mental health unit, the client says, “I asked my family to bring me in here to talk to someone, but now I don’t know where to begin.” Which response by the nurse would be most helpful? “Why not just start talking and see where it takes you?” “If I were you, I’d begin with what you were doing this morning.” “Perhaps you can start by sharing some of your most recent concerns.” Correct! “Don’t worry. Everyone who comes in here for the first time feels reluctant to talk.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The intake interview is usually the first contact with the client. It is intended to establish rapport, to help the nurse understand the client’s current problem and level of functioning, and to help the nurse formulate a nursing care plan. The clinician usually allows the client to set the pace of the interview and uses open-ended questions to elicit a comprehensive diagnostic picture of the client’s problems and level of coping. Sharing concerns is a good place to start the conversation because it will allow the client to express feelings. The response “Why not just start talking and see where it takes you?” is too general and does not provide the client with a focus on self. Telling the client not to worry is nontherapeutic and avoids addressing the client’s concerns. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Focusing on the client’s feelings will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 4 1 / 1 pts During a mental health intake interview, a young adult client who lives with his family rent free says, “I’m tired of not being able to offer my friends a beer just because my folks don’t believe in taking a drink socially.” Which nursing response would be therapeutic? “Well, I guess you could move out and live on your own if you wanted to.” “It seems that your parents expect you to follow their rules when you live under their roof.” Correct! 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do.’” Rationale: The therapeutic nursing response uses reflection, in which the nurse directs the content of the client’s message back for the client to review from a new perspective. This technique also includes an element of focusing on the crux of the issue—in this case, that it is his parents’ home and they set the rules for living in their home, just as he someday will in his. Telling the client to move out is giving advice or suggestions to the client prematurely. Although this technique can be useful in the working phase, it is usually nontherapeutic when the nurse needs to promote client understanding and selfexploration. Stating “You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?” is judgmental and poorly timed in that it humiliates the client unnecessarily. The client has acknowledged that he pays no rent, so there is no helpful purpose in reemphasizing this fact. Stating “Well, if you directly discussed your concerns with them, I guess it’s a case of ‘When in Rome, do as the Romans do’” is nontherapeutic in that it offers a cliché and expresses hopelessness and powerlessness, two emotions that the client is no doubt already experiencing. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. This will direct you to the correct option, the nursing response that focuses on the client’s concerns and feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 5 1 / 1 pts A nurse is participating in a care planning conference regarding care for a client whose spouse recently died. The registered nurse formulates a nursing diagnosis of dysfunctional grieving. Which priority intervention does the nurse expect to see incorporated into the plan? Monitoring the client’s sleep pattern Obtaining a physician’s prescription for an antidepressant Determining the client’s risk for violence toward self and others Correct! Assisting the client in resolving the grief through emotional, cognitive, and behavioral means Rationale: The priority intervention for a client with dysfunctional grieving is assessing the client’s risk for violence toward self and others. Although the nurse will assist the client in resolving the grief and will monitor the client’s sleep pattern, these are not priorities in the list of options given. Obtaining a physician’s prescription for an antidepressant is not a priority. Test-Taking Strategy: Use the process of elimination and the steps of the nursing process. Both monitoring the client’s sleep pattern and determining the client’s risk for violence toward self and others involve assessment. From these options, select the one that addresses the safety of the client. Review interventions for a client with dysfunctional grieving if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 6 1 / 1 pts A client in the mental health unit tells the nurse, “My husband makes all the decisions about money, but I’m the one who’s making the money now, not him. He needs to back off, but he’s always directing every decision we make.” Which nursing response would be the most therapeutic? “Have you told your husband to back off”? “You’re making the most money, so the decisions should be left to you.” “How do you feel the money decisions could best be handled in your household?” Correct! “You seem frustrated with your husband’s habit of controlling financial decisions.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The therapeutic nursing response is the one that provides a broad opening or statement and is focused on the client’s feelings. In this response, the nurse will be able to assess what the client believes concerning family financial decision-making. Asking “Have you told your husband to ‘back off’?” is improperly paraphrasing the client and assumes that the client’s stance is correct. Stating that “You’re making the most money, so decisions should be left to you” is inappropriate restating and provides an opinion; this response may be seen by the client as reassurance that her interpretation is being judged as correct. By stating “You seem to feel frustrated…,” the nurse is sharing perceptions, which may appear to be challenging to the client when used in this context. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Remember to focus on the client’s feelings and to provide the client the opportunity to communicate. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 7 1 / 1 pts A nurse is attending a care planning conference for a client who recently received a diagnosis of acquired immunodeficiency syndrome and is experiencing difficulty adjusting to the illness. The nurse should question which planned intervention for this client? Monitoring the client for signs of self-harm Helping the client verbalize concerns related to fear Assisting the client with problem-solving and decision-making 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Discouraging social networking to prevent the spread of infection Correct! Rationale: In planning care for a client experiencing difficulty in adjusting to an illness, the nurse develops interventions to promote (not discourage) social networking that will provide needed information to the client. The other options are appropriate interventions. Test-Taking Strategy: Use the process of elimination and note the strategic word “question.” Recalling that social support is important will direct you to the correct option. Also, note the relationship between the word “question” in the question and “discouraging” in the correct option. Review interventions for a client experiencing difficulty in adjusting to an illness if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Ques 0.75 / 1 pts tion 8 How does a client who has lost a spouse show that she is successfully completing the tasks of mourning? Select all that apply. Relating that its better “he went first” Correct! Reporting that sleeping alone was hard at first Correct! Purchasing a smaller car she is comfortable driving Correct Answer Heard explaining to family that illness “took” her husband Correct! Heard explaining to family that illness took her husband 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 9 1 / 1 pts A nurse is caring for a 15-year-old girl who has been hospitalized on the mental health unit for bipolar disorder. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. The nurse recognizes that the client is using which defense mechanism? Projection Regression Correct! Identification Intellectualization Rationale: Identification is the process by which a person tries to become like someone he or she admires by taking on the beliefs, mannerisms, or tastes of that person. Projection is attributing one’s thoughts or impulses to another person. Regression is retreating to a behavior characteristic of an earlier level of development. Intellectualization is excessive reasoning or logic used to avoid experiencing disturbed feelings. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Noting that the client is mimicking a characteristic of another person will direct you to the correct option. Review these defense mechanisms if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 10 1 / 1 pts A mental health home care nurse says to the client, “Do you feel ready to try attending a group session at the clinic?” The client shakes his head. Which nursing statement would be therapeutic? “No? Why not?” “You seem to be saying no. Would you tell me more about your reluctance?” Correct! “OK, but I hope you will let me know when you feel ready to attend a group session at the clinic.” “Perhaps a group session would be too overwhelming for you right now. How about just seeing me?” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The therapeutic nursing statement is seeking clarification. In this statement, the nurse is asking the client to put his ideas into words and explain what he means or feels. This encourages the client to express his reluctance and to try to work out any reservations about attending the group session. In responding, “No? Why not?” the nurse is using a confrontational style, which could lead to a regressive struggle. The nurse expresses doubt and uses a laissez-faire style regarding attending a group session at the clinic when the nurse states “… let me know when you feel ready to attend.” In stating “Perhaps a group session would be too overwhelming for you right now. How about just seeing me?” the nurse prematurely guesses the reasons for the client’s refusal, and this is not appropriate. Test-Taking Strategy: Draw on your knowledge of therapeutic communication techniques to answer this question. First eliminate the option containing the word “why.” To select from the remaining options, focus on the information in the question. The correct option provides the client the opportunity to verbalize feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 11 1 / 1 pts A single parent whose son was suspended from school for carrying a gun into the school says to the nurse, “I know he has no dad, but I’ve brought him up to know better, and anyway, where did he get the stupid gun? What should I do? He just won’t listen to me.” Which nursing response would be helpful at this time?“Boys who are cared for only by their moms are at highest risk for violent behavior.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “There is quite a bit that you can do. Let’s talk about what you’re already doing first.” Correct! “Do you know all of your son’s friends, or is he left alone after school because you work?” “Many young people die of gunshots every day in this country, so your son’s behavior is unacceptable.” Rationale: It is important to help parents to identify children at risk for violent behavior. Unfortunately, this young person has already engaged in threatening and potentially violent behavior, but there are parenting measures and therapies that this single parent can use to help her son express his feelings of anger verbally rather than by acting out. The nurse responds nontherapeutically in telling the mother that boys who are cared for only by their mothers are at high risk for violence; this response could generate guilt in the mother. Asking “Do you know all of your son’s friends, or is he left alone after school because you work?” is both inappropriate and premature. Telling the woman that her son’s behavior is unacceptable is lecturing an upset parent, which is inappropriate. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques, and focus on the information in the question. Note that the client of the question (the mother) is asking the nurse for assistance. The correct option is the only option that addresses the mother’s concern and encourages verbalization. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 12 1 / 1 pts 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A client says to the nurse, “My health care provider says he thinks I’m ready to taper off my pain medication, but the new painkiller he prescribed doesn’t relieve my pain the way the other pill did. I get pain when I try to do things.” Which nursing response would be most supportive to the client? “Your physician feels that your body is physically ready to make the change in medication.” “I think you need to listen to your physician when it comes to taking such strong medication.” “Well, your health care provider is concerned that you will become physically dependent on the first painkiller.” “Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the medicine will be more effective.” Correct! 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The most supportive response is the one that addresses the client’s concern and provides a plan that will help minimize the client’s pain. If this nursing measure does not afford pain relief, then the nurse can report the client’s continued pain to the physician. In stating “Your physician feels that your body is physically ready to make the change in medication,” the nurse is shifting attention from the client’s feelings to the physician’s view. In telling the client that he or she needs to listen to the physician, the nurse is nontherapeutically giving advice and patronizing the client. Stating “Well, your health care provider is concerned that you will become physically dependent on the first painkiller” is a defensive response, and the nurse’s assertion about dependence may not be based on fact. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and focus on the subject, the client’s concern about pain relief. Eliminate the comparable or alike options that focus on the physician, not the client. From the remaining options, select the one that addresses the client’s concern. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 13 1 / 1 pts A client who was employed as a corporate manager before being laid off says to the nurse, “My wife thinks that I should work in a menial job to maintain our lifestyles until I find another job as a corporate manager, but I don’t feel I should have to humiliate myself like that.” Which nursing response would be therapeutic? Correct! “Have you shared your feelings with your wife?” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “You seem to feel that a less prestigious job would be humiliating for you.” “Oh, I agree with you. Let her get another job if she needs that much money.” “How soon will you be able to find work? If this is permanent, you may need to swallow your pride.” Rationale: The therapeutic response is the one that helps determine whether the client is sharing his feelings with his wife and providing her with the opportunity to join in the decision-making process. Stating “You seem to feel that a less prestigious job would be humiliating for you” is reflection to some degree; however, its focus is nontherapeutic because the nurse is making a premature judgment of the client’s concerns. In stating “Oh, I agree with you. Let her get another job if she needs that much money,” the nurse is using a nontherapeutic response of giving approval. “How soon will you be able to find work? If this is permanent, you may need to swallow your pride” is a probing question that the client is probably unable to answer and gives an unsolicited opinion, which is a nontherapeutic communication. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Note the words “shared your feelings” in the correct option. Remember to focus on the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 14 1 / 1 pts 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A young woman who has been divorced twice says to the nurse, “I’ve decided not to date men ever again! It never works out for me. Now I’m left with two children to bring up.” Which nursing response would be therapeutic? “Oh, me too. I always pick the worst kind of men, so I know just how you feel.” “Divorce is more difficult for children. Maybe you should focus on them for now.” “You’ve been unfortunate, but you seem to be focusing on yourself and what you have to do.” “You talk about how the divorces affected you. Tell me how your children are dealing with the loss.” Correct! 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When clients experience loss, they can become self-absorbed. In responding, “You talk about how the divorces affected you. Tell me how your children are dealing with the loss,” the nurse is trying to refocus the client’s attention on her children and their needs during this time. By stating “Oh, me too. I always pick the worst kind of men, so I know just how you feel,” the nurse personalizes and exaggerates the client’s problems, using a nontherapeutic response. In stating “Divorce is more difficult for children. Maybe you should focus on them for now,” the nurse is being judgmental when he or she should be refocusing the client’s energies. In stating “You’ve been unfortunate, but you seem to be focusing on yourself and what you have to do,” the nurse is responding with empathy, but the choice of wording suggests that the nurse is judging and blaming the client for not focusing on her children. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the option that is a nontherapeutic response and does not focus on the client’s concern. To select from the remaining options, note that the correct option is the only option that encourages the client to discuss the loss and its effect on her children. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 15 1 / 1 pts A client says to the nurse, “What does my psychiatrist mean when she says that my illness is biologically based?” Which nursing statement would be the most informative? “Mental illness always has its roots in the family.” “Mental illness is a result of environmental factors.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “Today we know that all mental illness is genetically inherited.” “There are many possible physical causes of mental illness, and they include problems in the brain.” Correct! Rationale: Biologically based mental illnesses are caused by neurotransmitter dysfunction, abnormal brain structure, inherited genetic factors, or other biological causes. Biologically influenced illnesses include schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, autism, anorexia nervosa, and attentiondeficit/hyperactivity disorder. Stating that all mental illness is a result of genetic factors or that it is caused by environmental factors or family dynamics is incorrect and not associated with a biologically based disorder. Test-Taking Strategy: Use the process of elimination. Eliminate the options that include the closed-ended words “always” and “all.” To select from the remaining options, focus on the words “biologically based” in the question, which will direct you to the correct answer. Review the causes of mental illness if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 16 1 / 1 pts A nurse is caring for a 39-year-old client who has experienced a mild brain attack (stroke). The client is recently widowed, is very active physically, and has two young sons. The client says to the nurse, “I don’t know what my sons will do if anything permanent happens to me. We have no other relatives, even on my late wife’s side.” Which nursing response would be therapeutic? 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! “You seem to be feeling very troubled.” “You are working to get better, but you’re worrying about things that aren’t going to happen.” “You seem to be feeling very powerless right now, yet you’re getting better, so why worry about what won’t happen?” “I am troubled that you are worried over the worst possible things that could happen rather than worrying about the efforts needed to strengthen your family situation.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The client has suffered two major losses and is expressing worry and concern about his health and his children. The correct response conveys the nurse’s expression of empathy and willingness to understand and help the client explore ways of coping with difficulties. In stating “You are working to get better and are doing so. But you are worrying about things that aren’t going to happen,” the nurse is making a pat and clichéd response that may or may not be true. In stating “You seem to be feeling very powerless right now, yet you’re getting better, so why worry about what won’t happen?” the nurse is displaying empathy but also minimizing the client’s feelings with a false reassurance. In stating “I am troubled that you are worried over the worst possible things that could happen rather than worrying about the efforts needed to strengthen your family situation,” the nurse is not focusing on the client’s concern, and the statement could be interpreted as minimizing or belittling by the client. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Select the option that focuses on the client’s feelings and encourages the client to express his feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 17 1 / 1 pts A client who has been admitted to a surgical unit with a diagnosis of cancer is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, “I’m not having surgery—you must have the wrong person! My test results were negative. I’ll be going home tomorrow.” The nurse recognizes that the client is engaging in the use of which defense mechanism? Correct! Denial 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Psychosis Delusions Displacement Rationale: Defense mechanisms protect us against anxiety. Denial is the defense mechanism used to block out painful or anxiety-inducing events or feelings. In this case, the client cannot deal with the upcoming cancer surgery and therefore denies that he or she is ill. Psychosis and delusions are not defense mechanisms. Displacement is acting out in anger or frustration with people who did not arouse the feelings. Test-Taking Strategy: Use the process of elimination and focus on the subject, defense mechanisms. First, eliminate the options that are not defense mechanisms. From the remaining options, focus on the data in the question to find the correct option. Review defense mechanisms if you had difficulty with this question Cognitive Ability: Understanding Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Question 18 1 / 1 pts A young adult client who is dying says to the nurse, “I keep asking my wife what I can do for her and our daughter before I die, but she refuses to tell me.” On the basis of the client’s statement, what is the appropriate nursing intervention? Teaching the client’s wife to write down her thoughts and feelings and to read them to her husband 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Saying to the client, “It sounds to me like your wife is truly comfortable and doesn’t want you to worry needlessly.” Talking with both the client and his wife about the importance of expressing their feelings and how to do it in healthy ways Correct! Talking with all family members, including the daughter, about the importance of expressing their concerns and feelings to the dying client Rationale: The appropriate nursing intervention is to help the client and spouse describe feelings that, left unspoken, might cause disruption and delay resolution. Teaching the client’s wife to write down her thoughts and feelings and read them to her husband is inappropriate without a prior determination of the wife’s feelings. In saying to the client, “It sounds to me as if your wife is truly comfortable and doesn’t want you to worry needlessly,” the nurse verbalizes a statement without a basis in fact, a nontherapeutic technique. Talking with all family members is inappropriate and could violate client confidentiality. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the option that does not address the client’s feelings and places the client’s feelings on hold. Next, eliminate the comparable or alike options because they both address an intervention with a family member before determining their feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 19 1 / 1 pts 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A 45-year-old client says to the nurse, “Since I left my wife and children, I can hardly make ends meet between child support and trying to support myself. I don’t know why I bother going to work when my wife and kids take just about everything I make.” Which nursing statement would be therapeutic? “I wonder why you left your wife and children.” “What would you expect your wife and children to do? They didn’t leave you.” “You seem to be very angry about carrying out your responsibility to your children.” “Do you feel that child support is designed to help children, not punish spouses who leave?” Correct! 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The nurse employs the therapeutic communication technique of seeking clarification to support the client in processing his feelings more specifically. In maintaining a neutral, unbiased, and nonjudgmental stance, the nurse can establish a trusting relationship with the client. In stating “I wonder why you left your wife and children,” the nurse changes the focus of the client’s concern and uses a “why” question that implies criticism and could cause the client to become defensive. “What would you expect your wife and children to do? They didn’t leave you” is sarcasm, which is nontherapeutic and alienates the client. In stating “You seem very angry about carrying out your responsibility to your children,” the nurse is making an interpretation and labeling the client’s feelings prematurely. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the option containing the word “why.” Next, eliminate the option that is sarcastic and the option that labels the client’s feelings. Also note that the correct option is the only option that focuses on the client’s concern and encourages the client to further verbalize feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 20 1 / 1 pts A survivor of a nightclub fire that killed more than 100 people says to the nurse, “It should have been me. How come I got out and they didn’t?” Which response by the nurse is appropriate? “I don’t know what to say. It was a terrible fire. I’m so sorry this happened.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “It seems that you’re blaming yourself for something that was beyond your control.” Correct! “It seems to me that you’re making this all about you when many people died in that fire.” “You should be thankful that you’re a survivor. The victims and their families lost, not you.” Rationale: The correct option involves the use of the communication technique of reflection and encourages the client to further verbalize his thoughts and feelings. In stating “I don’t know what to say. It was a terrible fire. I’m so sorry this happened,” the nurse is using a social response and the nontherapeutic communication technique of agreeing. In stating “It seems to me that you’re making this all about you when many people died in that fire,” the nurse is using the nontherapeutic communication techniques of disapproval and judging. In stating “You should be thankful that you’re a survivor. The victims and their families lost, not you,” the nurse is nontherapeutically lecturing the client. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that is therapeutic, involves the use of reflection, and encourages verbalization of the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 21 1 / 1 pts 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) When assisting with the plan of care of a client dying of cancer, the nurse seeks to have the client verbalize acceptance of his impending death. Which statement indicates to the nurse that this goal has been met? Correct! “I’d like to have my family here when I die.” “I’ll be ready to die once my daughter gets married.” “I want to go to my family reunion; then I’ll be ready to die.” “I just want to live to see my grandchildren graduate from college.” Rationale: Acceptance is often characterized by plans for death. Often the client wants loved ones near. Therefore the statement “I’d like to have my family here when I die” indicates acceptance of impending death. The incorrect options reflect the bargaining stage of coping, in which the client tries to negotiate with his or her God or with fate. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that demonstrate negotiation for something else to happen before death occurs. The correct option is the option that reflects acceptance. Review the stages of death and dying if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Mental Health Ques 1 / 1 pts tion 22 A client says to the nurse at the mental health clinic, “My husband and sister-in-law both have terminal illnesses, and my family 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) thinks that because I’m a nurse I should be able to handle everything.” Which nursing response would be therapeutic? “Are you saying you are overly involved and will need to emotionally distance yourself to be therapeutic for your family?” “Shame on them for expecting so much from you. Perhaps we need to schedule a family meeting so I can help you set them straight.” “I’m sorry to hear that your loved ones are so ill. As a nurse, you should be able to assist them by using your professional expertise. Perhaps that’s what your family expects from you.” “You’ve seen your loved ones dealing with some troubling events recently. Sounds as if you feel that your family expects more from you than from others in the family because you’re a nurse.” Correct! 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The therapeutic response is the one in which the nurse makes observations and then clarifies his or her perception of what the client has said. Stating “Are you saying you are overly involved and will need to emotionally distance yourself to be therapeutic for your family?” is paraphrasing, a therapeutic technique, but this response is premature and reflects unfounded assumptions. In stating “Shame on them for expecting so much from you. Perhaps we need to schedule a family meeting so I can help you set them straight,” the nurse expresses disapproval, a nontherapeutic communication technique, and then offers to “beat up” the family verbally in a family intervention. The statement “I’m sorry to hear that your loved ones are so ill. As a nurse, you should be able to assist them, using your professional expertise. Perhaps that’s what your family expects from you,” expresses sympathy but also lectures the client. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that specifically addresses the client’s feelings and encourages verbalization about the client’s concern. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 23 1 / 1 pts A 79-year-old client, recently widowed, says to the nurse, “My wife kept up our condominium single-handedly, and now my kids expect me to cook and clean for myself. I’m not lazy, but I don’t know how to cook and I’ve burnt myself twice just frying up what was supposed to be bacon and eggs. I’m so frustrated and I’ve already lost 10 pounds this month.” Which initial nursing statement should the nurse make to the client? 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “I’m calling the health care provider immediately to obtain a homemaker for you!” “It seems as if you feel lost without your wife and maybe a bit ignored by your children.” Correct! “First things first. What are you doing eating bacon and eggs? That’s not a good meal for you.” “Meals-on-Wheels can help you minimize the frustration you are having cooking. Are you a member of the local senior center?” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The client is exhibiting grief over the recent loss of his wife; feelings of insecurity, inexperience, and helplessness; weight loss (a vegetative sign of depression); evidence of poor nutritional habits; isolation; and a lack of safety in activities of daily living. The initial nursing statement should seek clarification of the client’s feelings so that the nurse can estimate the extent of mood alteration. In stating “I’m calling the health care provider immediately to obtain a homemaker for you!” the nurse is responding too abruptly. Although the stated intervention may be a part of mutual planning, the client may not need or qualify for such support at this time; more data should be gathered. In stating “First things first. What are you doing eating bacon and eggs? That’s not a good meal for you,” the nurse begins by ordering data from the client but veers off into expressing disapproval of the one meal that the client has cited, which may not be representative of his dietary habits. The nurse jumps to conclusions on the basis of inadequate information, and being judgmental is nontherapeutic. Saying, “Meals-on-Wheels can help you minimize your frustration. Are you a member of the local senior center?” jumps prematurely to referral to community resources that may be helpful. However, it is too early to address resources; a complete assessment of the client’s stated complaints should be obtained first. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. This will direct you to the correct option, which is the only option that addresses the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 24 1 / 1 pts A physician tells a client that she has cancer, that her illness is terminal, and that she has a 6-month prognosis. After the physician leaves the client’s room, which therapeutic statement should the nurse make to the client? 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “I am so sorry about this. You are my favorite client, and I will take good care of you.” “What did your health care provider tell you about your condition? Can you tell me what you’re thinking about?” Correct! “Do you have any questions about what is happening with you? I can assure you that I will do everything I can to help minimize your pain.” “Do you want me to get the phone so you can talk to your loved ones, or do you have questions for me about what’s happening with you?” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When communicating with the dying client and those who grieve, the nurse should use statements that indicate a willingness to follow the client’s lead. Openended statements such as “Can you tell me what you are thinking about?” are appropriate and encourage verbalization of feelings. In stating “I am so sorry about this. You are my favorite client, and I will take good care of you,” the nurse expresses sympathy but provides only a social response. By stating “Do you have any questions about what is happening with you? I can assure you that I will do everything I can to help minimize your pain,” the nurse begins with a therapeutic response but then gives a false reassurance. By stating “Do you want me to get the phone so you can talk to your loved ones, or do you have questions for me about what’s happening with you?” the nurse demonstrates discomfort and is seemingly reluctant to offer help. In this statement the nurse tells the client that the nurse would prefer that the client discuss feelings and concerns with loved ones. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. The correct option focuses on the client’s feelings and encourages client verbalization. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 25 1 / 1 pts The wife of a client who is dying says to the nurse, “I am able to take off the 6 months from work our health care provider feels that my husband will live, but what if he lives beyond that time?” Which therapeutic response should the nurse make? “Only you and your husband can determine how you should best allocate your work leave.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “Your husband has managed to be active up to now, so he could live longer than predicted, but his actual life span remains unclear.” “Are there other options for you in taking work leave? What are your thoughts about reducing your work hours at first so that you can extend your compassionate leave?” Correct! “Why not write down the pros and cons of taking work leave all at once and any other options and then decide with your husband and family which would be most helpful?” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: In end-of-life nursing care, the caregiver is often asked, “How long?” or “What should I do?” by family members and the dying clients themselves. The nurse can convey information and make limited but realistic predictions, such as presenting the client’s stable or deteriorating physiological condition. Discussing options and alternative solutions with the family that can be added to the process of decision-making can be helpful. Simple alternatives can be used as examples if the family or client seems unable to begin to problem-solve. By stating “Only you and your husband can determine how you should best allocate your work leave,” the nurse avoids any discussion with the family member. By stating “Your husband has managed to be active up to now, so he could live longer than predicted, but his lifespan remains unclear,” the nurse begins to discuss physiological issues but is so vague that in the end the statement offers no support. By stating “Why not write down the pros and cons of taking work leave all at once and any other options, and then decide with your husband and family which would be most helpful?” the nurse makes suggestions but leaves the family member with little to use for decision-making. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that assesses and explores with the client (the wife). Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 26 1 / 1 pts The wife of a dying man is ignoring his rapid physiological decline and imminent death. She continues with her usual activities, exhibits inability to remember what others have just told her, and misses important appointments. Which therapeutic statement should the nurse make to the wife? 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “It isn’t unusual for family to suffer from anticipatory grief when a loved one is dying.” Correct! “I cannot emphasize how much your husband needs you to be there for him right now. He is in the stage of denial.” “You will need to concentrate on getting to these appointments on time and write down what everyone says so you will remember.” “Can you talk about what’s happening to you right now? Your behavior is not appropriate at this stage of your husband’s illness. You seem to be having sympathy pains for him, like men during their wives’ pregnancies.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Anticipatory grief is premourning with specific clinical manifestations. The signs of anticipatory grief include feeling empty and lost, fatigued, and numb. Other behaviors include unreality and disbelief, periods of weeping or rage, a desire to run away from the situation, micromanagement of the client’s care, anger at the caregivers and the dying client, pronounced dependency, and fear. By describing this syndrome as common, the nurse offers understanding and assists the spouse in becoming more aware of her feelings and behaviors. This will free her from guilt and enhance her ability to deal with the situation. In stating “I cannot emphasize how much your husband needs you to be there for him right now. He is in the stage of denial,” or “You will need to concentrate on making these appointments on time and write down what everyone says so you will remember,” the nurse expresses disapproval of the spouse’s behavior, a nontherapeutic response that will probably cause the client to feel guilty. In stating “Can you talk about what’s happening to you right now? Your behavior is not appropriate at this stage of your husband’s illness. You seem to be having sympathy pains for him, like men during their wives’ pregnancies,” the nurse demeans the spouse’s behavior and makes a judgmental comment that will probably result in an angry and guilty response from the spouse. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that express disapproval of the spouse’s behavior. Next, eliminate the option that demeans the spouse’s behavior, another nontherapeutic technique. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 27 1 / 1 pts 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) An older adult client who is dying says to the nurse, “My son is 40 years old, but he works in a very poorly paying job and is always borrowing money from me. I don’t know how he’s going to manage without me.” Which response by the nurse would be therapeutic? “Could you share your feelings with your son just as you have with me?” Correct! “Sounds as if your son will never grow up and learn to take care of himself.” “Goodness. At 22, I supported myself and never asked my mother for anything.” “I wonder why you’re so worried about your adult son when you need to concentrate on you?” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: It is important for both the dying client and his or her significant others to resolve concerns by discussing issues, and the nurse needs to encourage this communication. “Sounds as if your son will never grow up and learn to take care of himself,” and “Goodness. At 22, I supported myself and never asked my mother for anything” are both judgmental responses. By stating “I wonder why you are so worried about your adult son when you need to concentrate on you?” the nurse diverts the focus from the client’s expressed concerns. Changing the subject is nontherapeutic when the client’s feelings are ignored. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that are judgmental responses and ignore the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Question 28 1 / 1 pts The widow of a man who was killed a week ago in a hit-and-run accident while walking the family dog says, “I should have just let the dog run in the backyard or gone with my husband. Our own parish priest hit my husband and finally surrendered to the police. He brought a lawyer with him because he’s worried about himself, not my husband. I hate him so much, my stomach hurts.” Which nursing statement would be therapeutic? “Of course you’re angry. Who wouldn’t be? Yet nothing is ever clear cut, is it?” “You not only lost your husband but also learned it was at the hands of someone you looked up to.” Correct! 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “You’re having stomach pain? You should get checked for an ulcer or other gastric problem.” “I wouldn’t blame you if you never entered a church again. This is a terrible thing for the head of a church to do.” Rationale: The therapeutic statement is the one that seeks clarification. By stating “Of course you’re angry. Who wouldn’t be? Yet nothing is ever clear cut, is it?,” the nurse agrees with the widow and then uses a social philosophic stance. This response is nontherapeutic. By stating “You’re having stomach pain? Sounds like you need to get checked for an ulcer or other gastric problem,” the nurse changes the focus from the widow’s expression of feelings to an expression of somatic distress. Sensations of somatic distress are common for a brief time during bereavement. However, if these symptoms were to persist, the nurse would then be correct to encourage the widow to get checked for physical problems. By stating “I wouldn’t blame you if you never entered a church again. This is a terrible thing for the head of a church to do,” the nurse agrees with the widow and judges the perpetrator. This response is also nontherapeutic. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that focuses on the subject, encourages the client’s (widow’s) expression of feelings, and seeks clarification. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 29 1 / 1 pts 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A single mother whose only son died 2 months ago says to the nurse, “I’ve been bothered at work with thoughts of my son. Suddenly I’ll think of something awful I said to him years ago or some punishment I gave him because he’d been bad.” Which plan should the nurse include in caregiving? Scheduling the client for an appointment with the psychiatrist because this is a pathological manifestation Calling the physician to report that the client is at a high risk for suicide and increasing the frequency of visits with the client Seeking emergency certification for the psychiatric inpatient unit at the community hospital because of high lethality concerns and visiting the client daily Explaining that bereaved persons often describe intrusive thoughts of negative experiences with the deceased and then increasing the frequency of nurse-client visits Correct! 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: It is common for grieving people to experience intrusive reexperiences or compulsive reenactments of interactions, including negative ones, with deceased loved ones. Bad dreams and diminished ability to concentrate may also occur. Therefore, scheduling an appointment with the psychiatrist is unnecessary, as is seeking emergency certification for the psychiatric inpatient unit. These options indicate that the nurse is making a premature interpretation that the client is at high risk for suicide. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that indicate that the client is a lethality risk. To select from the remaining options, note the relationship between the data in the question and the correct option. Review the grief response if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 30 1 / 1 pts A client who is a physician says to the nurse, after receiving a diagnosis of terminal lung cancer, “All my life I took care of my clients, and now my family is taking care of me.” Which statement is a therapeutic nursing response? Correct! “Your family is caring for you now.” “Well, you’d expect them to care for you, wouldn’t you?” “It is an honor for all of us to care for you. We want to help you.” “You can look back on so many wonderful people you saved and cared for.” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The client makes a statement that reflects powerlessness. In the correct option, the nurse uses the therapeutic communication technique of paraphrasing to enable the client to hear his own statement and express his feelings more completely, if he is able to express them. By stating “Well, you’d expect them to care for you, wouldn’t you?” the nurse uses sarcasm that implies that his care may be a responsibility his family feels burdened by. “It is an honor for all of us to care for you. We want to help you” and “You can look back on so many wonderful people you saved and cared for” are nontherapeutic platitudes that do not focus on the client’s concern. Test-Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. Eliminate the comparable or alike options that do not address the client’s feelings. From the remaining options, select the option that addresses the client’s feelings and encourages expression of feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Question 31 1 / 1 pts The parents of a 20-year-old who was killed while driving drunk say to the nurse, “We’re so devastated, but we are also angry that she would drink and drive when we told her over and over not to.” Which statement by the nurse would be therapeutic? “Young people don’t always obey their parents.” “Everyone feels guilt or anger when they lose a loved one.” “Does anyone in the family have a drinking or drug problem?” 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “Your sadness over losing your daughter is mixed with anger at her driving while intoxicated.” Correct! Rationale: Anger, a component of the bereavement phenomenon, is a common emotion. In saying, “Young people don’t always obey their parents,” the nurse makes a closed-ended statement that is lecturing in tone. In stating “Everyone feels guilt or anger when they lose a loved one,” the nurse makes a preachy and nontherapeutic intellectualization statement. In stating “Does anyone in the family have a drinking or drug problem?” the nurse changes the subject and takes the focus away from facilitation of the expression of feelings with an insensitive statement that may intensify the parents’ anger. Test-Taking Strategy: Use the process of elimination. Note the relationship between the data in the question and the correct option. Also note that the correct option is the only option that focuses on the clients’ feelings. Review therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Ques 1 / 1 pts tion 32 A nursing student is assigned to work in the emergency department to assist victims after a tornado. The student says to the nurse in charge, “I don’t know how to help these parents. Their son was just decapitated by a flying piece of glass, and they won’t leave him. They did mention that they are Catholic.” Which intervention does the nurse suggest for inclusion in a plan of immediate care for the family? Telling the student not to disturb the family until the end of shift 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Calling their family priest immediately to come help them to let their son go Asking the emergency department physician to join the student in requesting that the family let the nursing staff care for their son Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son’s body to the nurses Correct! Rationale: This question presents a sad and troubling story of a family needing time to grieve in the face of a catastrophic loss. The nurse’s plan to join the family will provide support to the family. The nurse should call the family priest but first must ascertain that the family does wish to talk to a priest. Telling the student not to disturb the family until the end of shift does not provide support to the family. Asking the emergency department physician to join the student in requesting that the family let the nursing staff care for their son is inappropriate. This also represents a redundancy of tasks for personnel in a busy emergency department. Test-Taking Strategy: Use the process of elimination. Focus on the subject in the question, and note that the correct option is the only option that provides support to the victim’s family. Review nursing interventions related to grief and loss if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Question 33 1 / 1 pts A nurse is caring for a bereaved man with acquired immunodeficiency syndrome who lost his twin brother in a rock- 7/19/2021 Module 3 Exam: HESI VN TXGRP 1912COHORT(VNE 39) climbing accident a month ago. Which statement by the client should cause the nurse to be concerned? Correct! “Lately I’ve been feeling that life isn’t that great.” “You’d have thought that I would be the one to die first.” “I should have made him stay home. He was always clumsy.” “I miss him so much. We were close and talked almost daily.” Rationale: The nurse needs to be alert to statements by clients that might be indicative of suicidal ideation. On hearing such a statement, the nurse must conduct a lethality assessment to examine the meaning of the client’s statement more closely. The client statement “Lately I’ve been feeling that life isn’t that great” should alert the nurse that the client may be experiencing suicidal ideation. In the statement “You’d have thought that I would be the one to die first,” the client is expressing anger and guilt, both normal components of bereavement. In the statement “I should have made him stay home. He was always clumsy,” the client is expressing guilt. In the statement “I miss him so much. We were