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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.
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An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
- A. Encourage the student to use the alternative coping mechanism of relaxation exercises.
- B. Complete the problem-solving process for the client.
- C. Work through the problem-solving process with the client.
- D. Encourage the client to keep a journal.
Correct Answer: C
Rationale: The correct answer is C: Work through the problem-solving process with the client. This option promotes empowerment and autonomy by guiding the client to develop their problem-solving skills. It allows the nurse to offer support and guidance without taking over the process entirely, fostering independence and self-efficacy. Encouraging the client to actively participate in finding solutions can help build confidence and improve their ability to handle similar situations in the future.
Explanation for other choices:
A: Encouraging relaxation exercises can be helpful for managing anxiety, but it does not directly address the underlying issue of developing problem-solving skills.
B: Completing the problem-solving process for the client does not empower the client to learn how to address similar challenges independently.
D: Keeping a journal can be a helpful tool for self-reflection and managing emotions, but it does not specifically address the client's difficulty with independent problem-solving.
A nurse understands that the abnormal secretion of growth hormone may play a role in which illness?
- A. Schizophrenia
- B. Anorexia nervosa
- C. Alzheimers disease
Correct Answer: B
Rationale: The correct answer is B: Anorexia nervosa. Growth hormone abnormalities can contribute to the development of anorexia nervosa by affecting metabolism and body composition. Increased levels of growth hormone can lead to muscle wasting and weight loss, which are common symptoms of anorexia nervosa. In contrast, schizophrenia is primarily associated with neurotransmitter imbalances, Alzheimer's disease is linked to neurodegeneration, and diabetes is often related to insulin abnormalities.
A 6-year-old boy uses his fathers flashlight to explore his 3-year-old sisters genitalia. According to Freud, in which stage of psychosocial development should a nurse identify this behavior as normal?
- A. Oral
- B. Anal
- C. Phallic
- D. Latency
Correct Answer: C
Rationale: The correct answer is C: Phallic stage. In Freud's psychosexual stages of development, the phallic stage occurs around ages 3 to 6. During this stage, children become curious about their own bodies and those of others. The boy exploring his sister's genitalia is displaying normal curiosity associated with this stage. The Oedipus complex and Electra complex also occur during this stage, where children develop feelings towards the opposite-sex parent. Choices A, B, and D do not align with the behaviors described in the scenario and are associated with different stages of development (oral, anal, and latency).
Which client statement may indicate a transference reaction?
- A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life.
- B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor.
- C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself.
- D. My mother is the source of my problems. She has always told me what to do and what to say.
Correct Answer: A
Rationale: Step 1: The client's statement "I need a real nurse" suggests a desire for a particular type of nurse, implying a transfer of feelings from a significant person onto the nurse.
Step 2: The client mentioning the nurse's age and relationship dynamics ("young enough to be my daughter") indicates projection of unresolved emotions onto the nurse.
Step 3: The client's reluctance to share personal information and discomfort with the nurse's perceived identity further supports the presence of transference reactions.
Summary: Option A is correct as it demonstrates transference by projecting emotions onto the nurse based on age and personal dynamics. Other choices lack clear indications of transference and focus on different issues like entitlement, social interaction difficulties, and blaming family members.
At what point should the nurse determine that a client is at risk for developing a mental disorder?
- A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
- B. When maladaptive responses to stress are coupled with interference in daily functioning
- C. When the client communicates significant distress
- D. When the client uses defense mechanisms as ego protection
Correct Answer: B
Rationale: The correct answer is B. When maladaptive responses to stress are coupled with interference in daily functioning, the nurse should determine that a client is at risk for developing a mental disorder. This is because maladaptive responses to stress, such as excessive worry or avoidance behaviors, can be early signs of mental health issues. When these responses start impacting daily functioning, such as affecting work or relationships, it indicates a higher level of risk for a mental disorder. Choices A, C, and D are incorrect because they do not specifically address the combination of maladaptive responses to stress and interference in daily functioning, which are key indicators of potential mental health issues.