During an admission assessment of an adolescent client, the nurse inquires about friends or peer groups. The adolescent smiles and jokingly tells the nurse that "I consider myself a loner and I don't need any friends."
The nurse's next action is to:
1. Ask the client how he/she gets along in school.
2. Ask the client to explain why he/she feels this way.
3. Document this in the admission assessment.
4. Encourage exploration of feelings.
4
Rationale: To avoid the possibility that this statement is a symptom characteristic of a further problem, the nurse utilizes therapeutic communication to explore the adolescent's perception of self, as adolescents' have a need for peer acceptance. Isolation could be symptomatic of an underlying problem. The findings should be documented and shared with the treatment team, but this is not the priority action at this time. Asking the client about getting along in school is not therapeutic and is an example of changing the subject. Asking the client to explain feelings is not therapeutic.
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