which action should the nurse implement during the termination phase of the nurse client relationship
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HESI Mental Health

1. Which action should the nurse implement during the termination phase of the nurse-client relationship?

Correct answer: D

Rationale: During the termination phase of the nurse-client relationship, it is essential for the nurse to help summarize accomplishments. This action provides closure by reflecting on the progress and goals achieved during treatment. It reinforces the positive aspects of the therapeutic relationship and helps the client acknowledge their growth and achievements. Choices A, B, and C are incorrect. Identifying new problem areas is not appropriate during termination, as the focus should be on closure. Confronting changes not completed may create tension and disrupt the positive closure process. Exploring the client's past in depth is more suitable for earlier stages of the therapeutic relationship, not during termination.

2. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?

Correct answer: B

Rationale: The correct intervention for a client diagnosed with paranoid schizophrenia who believes in paranoid delusions is to ask one nurse to spend time with the client daily. Establishing a trusting relationship with a consistent caregiver can help reduce anxiety and foster a sense of security. Choice A is incorrect because directly challenging the client's beliefs may increase distress. Choice C might overwhelm the client with paranoia in a group setting. Choice D does not address the need for a trusting relationship with a specific caregiver.

3. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

4. The LPN/LVN is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which intervention is most appropriate?

Correct answer: B

Rationale: Asking the client to describe the voices he hears is the most appropriate intervention in this situation. It helps the nurse assess the content and severity of the hallucinations, enabling the planning of appropriate interventions. Choice A is not as effective as directly addressing the hallucinations. Choice C may lead to mistrust as the client believes the voices are real. Choice D does not address the client's immediate need related to the hallucinations.

5. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.

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