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A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.
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A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
- A. Mental Status Examination (MSE)
- B. Brief Patient Health Questionnaire (Brief PHQ)
- C. Abnormal Involuntary Movements Scale (AIMS)
- D. Scale for Assessment of Negative Symptoms (SANS)
Correct Answer: A
Rationale: The correct answer is A: Mental Status Examination (MSE). A MSE is crucial to assess cognitive function, orientation, memory, attention, and other mental aspects in older adults with suspected cognitive disorders. It helps identify cognitive deficits and guide appropriate interventions. Brief PHQ (B) focuses on mood disorders, AIMS (C) evaluates movement disorders, and SANS (D) assesses negative symptoms in psychiatric disorders, which are not specific to cognitive disorders. In summary, the MSE is the most relevant tool for assessing cognitive functions in this scenario.
Which intervention should a nurse prioritize when caring for a client with alcohol use disorder?
- A. Helping the client identify positive personality traits
- B. Providing adequate hydration and rest
- C. Confronting denial and defense mechanisms
- D. Educating the client about alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing adequate hydration and rest. This intervention is crucial because individuals with alcohol use disorder often experience dehydration and fatigue due to excessive alcohol consumption. Hydration helps to flush out toxins and restore electrolyte balance, while rest supports physical and mental recovery. Helping the client identify positive personality traits (A) may be beneficial in building self-esteem but is not as urgent as addressing physical needs. Confronting denial and defense mechanisms (C) may lead to resistance and hinder the therapeutic relationship. Educating the client about alcohol misuse (D) is important but should be done after addressing immediate physical needs.
A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
- A. Telling his parents that he doesn't want to talk about the suicide attempt.
- B. Stating that he wants to be with his peers more than with his parents.
- C. Preferring to eat his meals while watching TV.
- D. Planning to give his CD collection to his girlfriend.
Correct Answer: D
Rationale: The correct answer is D: Planning to give his CD collection to his girlfriend. This behavior indicates the adolescent is making future plans involving giving away possessions, which could be a sign of continued suicidal ideation. Giving away prized possessions is often seen as a way of saying goodbye or preparing for death. Choices A, B, and C do not necessarily indicate ongoing suicidal intent. A may suggest avoidance, B may indicate a desire for peer support, and C may be a personal preference. Therefore, D is the most concerning behavior that warrants immediate attention.
A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing which of the following types of crisis?
- A. Adventitious
- B. Internal
- C. Maturational
- D. Situational
Correct Answer: D
Rationale: The correct answer is D: Situational crisis. The client's denial of the HIV diagnosis and refusal of treatment indicate an acute crisis triggered by a specific event or situation - the new HIV diagnosis. In a situational crisis, individuals struggle to cope with a sudden and unexpected event, leading to cognitive dissonance and emotional distress. The client's disbelief and avoidance of the reality of the diagnosis demonstrate a maladaptive response to the crisis. Adventitious crisis (A) refers to events like natural disasters, which are not applicable here. Internal crisis (B) involves inner conflicts, not evident in this scenario. Maturational crisis (C) arises from developmental life stages, which is not the case here.
A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?
- A. Dialectical behavior therapy
- B. Behavioral contract
- C. Milieu therapy
- D. Safety plan
Correct Answer: D
Rationale: The correct answer is D: Safety plan. For a client with borderline personality disorder, a safety plan is crucial to prevent self-harm or suicidal behaviors. This intervention helps the client identify triggers, coping strategies, support resources, and steps to take in a crisis. A: Dialectical behavior therapy is a comprehensive treatment, not just a discharge plan. B: Behavioral contract may not address the immediate safety concerns. C: Milieu therapy focuses on the therapeutic environment, not individual discharge planning.