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During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.
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A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the clients appraisal of the situation? Select all that apply.
- A. What resources have you used previously in stressful situations?
- B. Have you ever experienced a similar stressful situation?
- C. Who do you think is to blame for this situation?
- D. Why do you think you were fired from your job?
Correct Answer: A
Rationale: The correct answer is A: "What resources have you used previously in stressful situations?" This question is the best choice as it focuses on understanding the client's coping mechanisms and resilience. By asking about previous resources used, the nurse can assess the client's strengths and support systems.
Choice B is incorrect because asking if the client has experienced a similar situation does not directly address the client's current appraisal of the situation.
Choice C is incorrect as it focuses on assigning blame, which may not be helpful in understanding the client's perspective and emotions.
Choice D is also incorrect because asking why the client thinks they were fired may lead to a defensive response and may not necessarily provide insight into the client's appraisal of the situation.
A psychiatric nurse uses Sullivans theories in group and individual therapy. According to Sullivan and other theorists like him, how are client symptoms viewed behaviors that are maintained because they are reinforced?
- A. Client symptoms are viewed as responses to anxiety arising from interpersonal relationships.
- B. Client symptoms are viewed as internal conflicts arising from early childhood trauma.
- C. Client symptoms are viewed as the misinterpretations of experiences.
- D. Client symptoms are viewed as learned
Correct Answer: B
Rationale: The correct answer is B because Sullivan and other theorists like him believe that client symptoms are viewed as internal conflicts arising from early childhood trauma. Sullivan emphasized the impact of early relationships on personality development, suggesting that unresolved conflicts from childhood can manifest as symptoms in adulthood. This perspective aligns with psychodynamic theories that emphasize the role of unconscious processes and early experiences in shaping behavior.
Choice A is incorrect because it focuses on anxiety arising from interpersonal relationships, which is more aligned with interpersonal theories rather than Sullivan's emphasis on childhood experiences. Choice C is incorrect as it suggests misinterpretations of experiences, which does not fully capture the depth of internal conflicts highlighted by Sullivan. Choice D is incorrect as it simplifies client symptoms as learned behaviors without considering the underlying emotional conflicts rooted in early childhood experiences, as emphasized by Sullivan.
A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
- A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
- B. I wont stop taking this medication abruptly, because there could be serious complications.
- C. I will not drink alcohol while taking this medication.
- D. I wont take extra doses of this drug because I can become addicted.
Correct Answer: A
Rationale: The correct answer is A because the statement indicates a misunderstanding. Benzodiazepines do not require routine blood monitoring for toxicity. Benzodiazepines are typically monitored based on clinical response and potential side effects. Choices B, C, and D are all correct statements related to benzodiazepine use, emphasizing the importance of not abruptly stopping the medication, avoiding alcohol, and not taking extra doses to prevent addiction.
What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship?
- A. Acknowledge the clients actions and generate alternative behaviors.
- B. Establish rapport and develop treatment goals.
- C. Attempt to find alternative placement.
- D. Explore how thoughts and feelings about this client may adversely impact care.
Correct Answer: B
Rationale: The correct answer is B: Establish rapport and develop treatment goals. During the introductory phase of the nurse-client relationship, establishing rapport is essential to build trust and a therapeutic alliance. Developing treatment goals collaboratively with the client sets the foundation for the care plan. This action promotes client engagement and empowerment. Acknowledging client actions and generating alternative behaviors (A) is more suited for later phases. Attempting to find alternative placement (C) is not appropriate in the introductory phase. Exploring how thoughts and feelings impact care (D) is important but not the priority during the orientation phase.
During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the mans loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurses action?
- A. The nurses action should be evaluated as unacceptable due to breech of cultural norms.
- B. The nurses action should be evaluated as empathetic, encouraging expression of feelings.
- C. The nurses action should be evaluated as the technique of offering self.
- D. The nurses action should be evaluated as inappropriate due to poor timing.
Correct Answer: A
Rationale: The correct answer is A because the nurse's action of hugging the man from Syria who just lost his son in a car accident breaches cultural norms. In many Middle Eastern cultures, physical touch, especially between unrelated individuals of the opposite sex, is considered inappropriate and can be seen as disrespectful. This can cause discomfort and may even offend the individual. In this scenario, the nurse should respect the man's cultural background and find alternative ways to show empathy and support, such as verbal expressions of sympathy or offering a comforting presence.
Choice B is incorrect because while the nurse may have intended to show empathy, the method of hugging was culturally inappropriate. Choice C is incorrect as offering self typically involves sharing personal experiences to build rapport, not physical touch. Choice D is also incorrect as the issue lies more with cultural norms rather than poor timing.