(Test Bank) The Art And Science For Mental Health Nursing

Norman, 3

Nursing

Test Bank

3rd Edition

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Test Bank for The Art And Science For Mental Health Nursing, The downloadable file consists of 365 pages, and the total size of the file is 17.52 MB. Purchase now only for highly discounted price.

Author(s): Norman

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Chapter 1: Practicing the Science and Art of Psychiatric Nursing Test BankMULTIPLE CHOICE1.Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community with serious and persistent mental illness? Within 3 months, the patient will:a.deny suicidal ideation.b.report a sense of well-being.c.take medications as prescribed.d.attend clinic appointments on time.ANS: BRecovery emphasizes managing symptoms, reducing psychosocial disability, and improving role performance. The goal of recovery is to empower the individual with mental illness to achieve a sense of meaning and satisfaction in life and to function at the highest possible level of wellness. The incorrect options focus on the classic medical model rather than recovery.DIF: Cognitive Level: Application REF: Pages: 2-3TOP: Nursing Process: Outcomes IdentificationMSC: NCLEX: Health Promotion and Maintenance2.A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse’s most caring comment.a.“Let’s discuss some means of coping other than suicide when you have these feelings.”b.“I understand why you’re so depressed. When I got divorced, I was devastated too.”c.“You should forget about your marriage and move on with your life.”d.“How did you get so depressed that hospitalization was necessary?”ANS: AThe nurse’s communication should evidence caring and a commitment to work with the patient. This commitment lets the patient know the nurse will help. Probing and advice are not helpful or therapeutic interventions.DIF: Cognitive Level: Application REF: Pages: 6-8TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity3.In the shift-change report, an off-going nurse criticizes a patient who wears heavy makeup. Which comment by the nurse who receives the report best demonstrates advocacy?a.“This is a psychiatric hospital. Craziness is what we are all about.”b.“Let’s all show acceptance of this patient by wearing lots of makeup too.”c.“Your comments are inconsiderate and inappropriate. Keep the report objective.”d.“Our patients need our help to learn behaviors that will help them get along in society.”ANS: DAccepting patients’ needs for self-expression and seeking to teach skills that will contribute to their well-being demonstrate respect and are important parts of advocacy. The on-coming nurse needs to take action to ensure that others are not prejudiced against the patient. Humor can be appropriate within the privacy of a shift report but not at the expense of respect for patients. Judging the off-going nurse in a critical way will create conflict. Nurses must show compassion for each other.DIF: Cognitive Level: Application REF: Page: 8TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment4.A nurse assesses a newly admitted patient with depression. Which statement is an example of “attending”?a.“We all have stress in life. Being in a psychiatric hospital isn’t the end of the world.”b.“Tell me why you felt you had to be hospitalized to receive treatment for your depression.”c.“You will feel better after we get some antidepressant medication started for you.”d.“I’d like to sit with you a while so you may feel more comfortable talking with me.”ANS: DAttending is a technique that demonstrates the nurse’s commitment to the relationship and reduces feelings of isolation. This technique shows respect for the patient and demonstrates caring. Generalizations, probing, and false reassurances are nontherapeutic.DIF: Cognitive Level: Application REF: Page: 8TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity5.A patient shows the nurse an article from the Internet about a health problem. Which characteristic of the web site’s address most alerts the nurse that the site may have biased and prejudiced information?a.Address ends in “.org.”b.Address ends in “.com.”c.Address ends in “.gov.”d.Address ends in “.net.”ANS: BFinancial influences on a site are a clue that the information may be biased. “.com” at the end of the address indicates that the site is a commercial one. “.gov” indicates that the site is maintained by a government entity. “.org” indicates that the site is nonproprietary; the site may or may not have reliable information, but it does not profit from its activities. “.net” can have multiple meanings.DIF: Cognitive Level: Comprehension REF: Page: 5 TOP: Nursing Process: EvaluationMSC: NCLEX: Health Promotion and Maintenance6.A nurse says, “When I was in school I learned to call upset patients by name to get their attention, but I read a descriptive research study that says that this approach doesn’t work. I’m going stop calling patients by name.” Which statement is the best appraisal of this nurse’s comment?a.One descriptive research study rarely provides enough evidence to change practice.b.Staff nurses apply new research findings only with the help from clinical nurse specialists.c.New research findings should be incorporated into clinical algorithms before using them in practice.d.The nurse misinterpreted the results of the study. Classic tenets of practice do not change.ANS: ADescriptive research findings provide evidence for practice but must be viewed in relation to other studies before practice changes. One study is not enough. Descriptive studies are low on the hierarchy of evidence. Clinical algorithms use flow charts to manage problems and do not specify one response to a clinical problem. Classic tenets of practice should change as research findings provide evidence for change.DIF: Cognitive Level: Analysis REF: Pages: 3-4 TOP: Nursing Process: EvaluationMSC: NCLEX: Health Promotion and Maintenance7.Two nursing students discuss career plans after graduation. One student wants to enter psychiatric nursing. The other student asks, “Why would you want to be a psychiatric nurse? All they do is talk. You’ll lose your skills.” Select the best response by the student interested in psychiatric nursing.a.“Psychiatric nurses practice in safer environments than other specialties. Nurse-to-patient ratios must be better because of the nature of patients’ problems.”b.“Psychiatric nurses use complex communication skills, as well as critical thinking, to solve multidimensional problems. I’m challenged by those situations.”c.“I think I’ll be good in the mental health field. I do not like clinical rotations in school, so I don’t want to continue them after I graduate.”d.“Psychiatric nurses don’t have to deal with as much pain and suffering as medical surgical nurses. That appeals to me.”ANS: BThe practice of psychiatric nursing requires a different set of skills than medical surgical nursing, although substantial overlap does exist. Psychiatric nurses must be able to help patients with medical and mental health problems, reflecting the holistic perspective these nurses must have. Nurse-patient ratios and workloads in psychiatric settings have increased, similar to other specialties. Psychiatric nursing involves clinical practice, not simply documentation. Psychosocial pain is real and can cause as much suffering as physical pain.DIF: Cognitive Level: Application REF: Page: 3TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment8.Which research evidence would most influence a group of nurses to change their practice?a.Expert committee report of recommendations for practiceb.Systematic review of randomized controlled trialsc.Nonexperimental descriptive studyd.Critical pathwayANS: BResearch findings are graded using a hierarchy of evidence. A systematic review of randomized controlled trials is Level A and provides the strongest evidence for changing practice. Expert committee recommendations and descriptive studies lend less powerful and influential evidence. A critical pathway is not evidence; it incorporates research findings after they have been analyzed.DIF: Cognitive Level: Application REF: Pages: 4-6 TOP: Nursing Process: AnalysisMSC: NCLEX: Safe, Effective Care Environment9.A bill introduced in Congress would reduce funding for the care of people with mental illnesses. A group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled?a.Advocacyb.Attendingc.Recoveryd.Evidence-based practiceANS: AAn advocate defends or asserts another’s cause, particularly when the other person lacks the ability to do that for him- or herself. Examples of individual advocacy include helping patients understand their rights or make decisions. On a community scale, advocacy includes political activity, public speaking, and publication in the interest of improving the individuals with mental illness; the letter-writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs.DIF: Cognitive Level: Comprehension REF: Page: 8TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment10.An informal group of patients discuss their perceptions of nursing care. Which comment best indicates a patient’s perception that his or her nurse is caring?a.“My nurse always asks me which type of juice I want to help me swallow my medication.”b.“My nurse explained my treatment plan to me and asked for my ideas about how to make it better.”c.“My nurse told me that if I take all the medicines the doctor prescribes I will get discharged soon.”d.“My nurse spends time listening to me talk about my problems. That helps me feel like I’m not alone.”ANS: DCaring evidences empathic understanding, as well as competency. It helps change pain and suffering into a shared experience, creating a human connection that alleviates feelings of isolation. The remaining options give examples of statements that demonstrate advocacy or giving advice.DIF: Cognitive Level: Application REF: Pages: 3-4|Page: 8TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity11.A patient who immigrated to the United States from Honduras was diagnosed with schizophrenia. The patient took an antipsychotic medication for 3 weeks but showed no improvement. Which resource should the treatment team consult for information on more effective medications for this patient?a.Clinical algorithmb.Clinical pathwayc.Clinical practice guidelined.International Statistical Classification of Diseases and Related Health Problems (ICD)ANS: AA clinical algorithm is a guideline that describes diagnostic and/or treatment approaches drawn from large databases of information. These guidelines help the treatment team make decisions cognizant of an individual patient’s needs, such as ethnic origin, age, or gender. A clinical pathway is a map of interventions and treatments related to a specific disorder. Clinical practice guidelines summarize best practices about specific health problems. The ICD classifies diseases.DIF: Cognitive Level: Application REF: Page: 6 TOP: Nursing Process: EvaluationMSC: NCLEX: Safe, Effective Care Environment12.Which historical nursing leader helped focus practice to recognize the importance of science in psychiatric nursing?a.Abraham Maslowb.Hildegard Peplauc.Kris Martinsend.Harriet BaileyANS: BAlthough all these leaders included science as an important component of practice, Hildegard Peplau most influenced its development in psychiatric nursing. Maslow was not a nurse, but his theories influence how nurses prioritize problems and care. Bailey wrote a textbook in the 1930s on psychiatric nursing interventions. Kris Martinsen emphasized the importance of caring in nursing practice.DIF: Cognitive Level: Knowledge REF: Page: 4 TOP: Nursing Process: N/AMSC: NCLEX: Psychosocial Integrity13.A nurse consistently strives to demonstrate caring behaviors during interactions with patients. Which reaction by a patient indicates this nurse is effective? A patient reports feeling:a.distrustful l of others.b.connected with others.c.uneasy about the future.d.discouraged with efforts to improve.ANS: BA patient is likely to respond to caring with a sense of connectedness with others. The absence of caring can make patients feel distrustful, disconnected, uneasy, and discouraged.DIF: Cognitive Level: Comprehension REF: Pages: 7-8 TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial IntegrityMULTIPLE RESPONSE1.An experienced nurse says to a new graduate, “When you’ve practiced as long as I have, you’ll instantly know how to take care of psychotic patients.” What is the new graduate’s best analysis of this comment? Select all that apply.a.The experienced nurse may have lost sight of patients’ individuality, which may compromise the integrity of practice.b.New research findings must be continually integrated into a nurse’s practice to provide the most effective care.c.Experience provides mental health nurses with the tools and skills needed for effective professional practice.d.Experienced psychiatric nurses have learned the best ways to care for psychotic patients through trial and error.e.Effective psychiatric nurses should be continually guided by an intuitive sense of patients’ needs.ANS: A, BEvidence-based practice involves using research findings to provide the most effective nursing care. Evidence is continually emerging; therefore, nurses cannot rely solely on experience. The effective nurse also maintains respect for each patient as an individual. Overgeneralization compromises that perspective. Intuition and trial and error are unsystematic approaches to care.DIF: Cognitive Level: Application REF: Pages: 2-3|Page: 6TOP: Nursing Process: Analysis MSC: NCLEX: Safe, Effective Care Environment2.Which patient statements identify qualities of nursing practice with high therapeutic value? (Select all that apply.) “The nurse:a.talks in language I can understand.”b.helps me keep track of my medications.”c.is willing to go to social activities with me.”d.lets me do whatever I choose without interfering.”e.looks at me as a whole person with different needs.”ANS: A, B, EEach correct answer demonstrates caring is an example of appropriate nursing foci: communicating at a level understandable to the patient, using holistic principles to guide care, and providing medication supervision. The incorrect options suggest a laissez-faire attitude on the part of the nurse, when the nurse should instead provide thoughtful feedback and help patients test alternative solutions or violate boundaries.DIF: Cognitive Level: Application REF: Pages: 6-8TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial IntegrityChapter 6: Legal and Ethical Basis for Practice Test BankMULTIPLE CHOICE1.A psychiatric nurse best implements the ethical principle of autonomy when he or she:a.intervenes when a self-mutilating patient attempts to harm self.b.stays with a patient who is demonstrating a high level of anxiety.c.suggests that two patients who are fighting be restricted to the unit.d.explores alternative solutions with a patient, who then makes a choice.ANS: DAutonomy is the right to self-determination, that is, to make one’s own decisions. When the nurse explores alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice.DIF: Cognitive Level: Application REF: Page: 81|Page: 84TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment2.Which action by a psychiatric nurse best supports patients’ rights to be treated with dignity and respect?a.Consistently addressing each patient by title and surname.b.Strongly encouraging a patient to participate in the unit milieu.c.Discussing a patient’s condition with another health care provider in the elevator.d.Informing a treatment team that a patient is too drowsy to participate in care planning.ANS: AA simple way of showing respect is to address the patient by title and surname rather than assuming that the patient would wish to be called by his or her first name. Discussing a patient’s condition with a health care provider in the elevator violates confidentiality. Informing a treatment team that the patient is too drowsy to participate in care planning violates patient autonomy. Encouraging a patient to participate in the unit milieu exemplifies beneficence and fidelity.DIF: Cognitive Level: Application REF: Page: 86TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment3.Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion:a.reveals that the nurse values the principle of justice.b.reinforces the autonomy of the two patients.c.violates the civil rights of the two patients.d.represents the intentional tort of battery.ANS: CPatients have a right to treatment in the least restrictive setting. Less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion removes the patient’s autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery.DIF: Cognitive Level: Application REF: Pages: 82-83|Page: 85TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment4.In a team meeting a nurse says, “I’m concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision.” Which ethical principle most clearly applies to this situation?a.Beneficenceb.Autonomyc.Fidelityd.JusticeANS: DThe nurse is concerned about justice, that is, the fair treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one’s own decisions. Fidelity is the observance of loyalty and commitment to the patient.DIF: Cognitive Level: Application REF: Page: 81 TOP: Nursing Process: PlanningMSC: NCLEX: Safe, Effective Care Environment5.Which scenario is an example of a tort?a.The primary nurse does not complete the plan of care for a patient within 24 hours of the patient’s admission.b.An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized.c.A patient’s admission status is changed from involuntary to voluntary after the patient’s hallucinations subside.d.A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed.a.The primary nurse does not complete the plan of care for a patient within 24 hours of the patient’s admission.b.An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized.c.A patient’s admission status is changed from involuntary to voluntary after the patient’s hallucinations subside.d.A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed.ANS: DA tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff members controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts.DIF: Cognitive Level: Application REF: Pages: 88-89 TOP: Nursing Process: EvaluationMSC: NCLEX: Safe, Effective Care Environment6.A nurse’s neighbor asks, “Why aren’t people with mental illness kept in state institutions anymore?” What is the nurse’s best response?a.“Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent.”b.“Less restrictive settings are now available to care for individuals with mental illness.”c.“Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed.”d.“Psychiatric institutions are no longer popular as a consequence of negative stories in the press.”ANS: BThe community is a less restrictive alternative than hospitals for the treatment of people with mental illness. The remaining options are incorrect and part of the stigma of mental illness.DIF: Cognitive Level: Application REF: Page: 82TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment7.Which nursing intervention demonstrates false imprisonment?a.A confused and combative patient says, “I’m getting out of here and no one can stop me.” The nurse restrains this patient without a health care provider’s order and then promptly obtains an order.b.A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall saying, “Stay in your room or you’ll be put in seclusion.”c.An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit.d.An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving.ANS: BFalse imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The patient in one distracter is not competent, and the nurse is acting beneficently. The patients in the other distracters have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team.DIF: Cognitive Level: Application REF: Pages: 88-89 TOP: Nursing Process: EvaluationMSC: NCLEX: Safe, Effective Care Environment8.A patient should be considered for involuntary commitment for psychiatric care when he or she:a.is noncompliant with the treatment regimen.b.sold sells and distributes illegal drugs.c.threatens to harm self and others.d.fraudulently files for bankruptcy.ANS: CInvoluntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.DIF: Cognitive Level: Comprehension REF: Pages: 82-83TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment9.A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, “Stop, stop! I don’t want to take that medicine anymore. I hate the side effects.” Select the nurse’s best initial action.a.Stop the medication administration procedure and say to the patient, “Tell me more about the side effects you’ve been having.”b.Say to the patient, “Since I’ve already drawn the medication in the syringe, I’m required to give it, but let’s talk to the doctor about skipping next month’s dose.”c.Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects.d.Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.ANS: APatients with mental illness retain their civil rights unless clear, cogent, and convincing evidence of dangerousness exists. The patient in this situation presents no evidence of being dangerous. The nurse, an as advocate and educator, should seek more information about the patient’s decision and should not force the medication.DIF: Cognitive Level: Analysis REF: Pages: 84-85TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment10.Several nurses are concerned that agency policies related to restraint and seclusion practices are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice?a.The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care.b.Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care.c.In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises.d.Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.a.The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care.b.Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care.c.In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises.d.Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.ANS: ANurses are professionally bound to uphold the American Nurses Association (ANA) standards of practice, regardless of lesser standards established by a health care agency or state. Conversely, if the agency standards are higher than the ANA standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.DIF: Cognitive Level: Application REF: Pages: 90-91TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment11.A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care?a.Health care providerb.Professionc.Hospitald.PatientANS: DAlthough the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient.DIF: Cognitive Level: Application REF: Pages: 90-91TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment12.An example of a breach of a patient’s right to privacy occurs when a nurse:a.asks a family to share information about a patient’s prehospitalization behavior.b.discusses the patient’s history with other staff members during care planning.c.documents the patient’s daily behaviors during hospitalization.d.releases information to the patient’s employer without consent.ANS: DThe release of information without patient authorization violates the patient’s right to privacy. The other options are acceptable nursing practices.DIF: Cognitive Level: Application REF: Page: 83|Pages: 85-87|Pages: 92-93TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment13.An adolescent hospitalized after a violent physical outburst tells the nurse, “I’m going to kill my father, but you can’t tell anyone.” Select the nurse’s best response.a.“You’re right. Federal law requires me to keep that information private.”b.“Those kinds of thoughts will make your hospitalization longer.”c.“You really should share this thought with your psychiatrist.”d.“I am obligated to share information with the treatment team.”ANS: DBreach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to the delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the father of the risk for harm.DIF: Cognitive Level: Application REF: Page: 87TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment14.A voluntarily hospitalized patient tells the nurse, “Get me the forms for discharge against medical advice so I can leave now.” What is the nurse’s best initial response?a.“I can’t give you those forms without your health care provider’s knowledge.”b.“I will get them for you, but let’s talk about your decision to leave treatment.”c.“Since you signed your consent for treatment, you may leave if you desire.”d.“I’ll get the forms for you right now and bring them to your room.”ANS: BA patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient’s wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms cannot be given without the health care provider’s knowledge is not true. Facilitating discharge without consent is not in the patient’s best interest before exploring the reason for the request.DIF: Cognitive Level: Application REF: Page: 83TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment15.The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will “never get any treatment.” Which reply by