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If the client admits that incidences of domestic abuse are occurring, which nursing intervention is most beneficial?
- A. Offering the victim money to leave home
- B. Identifying resources for shelter and safety
- C. Recommending termination of the abusive relationship
- D. Suggesting joint counseling with a therapist or clergyman
Correct Answer: B
Rationale: Providing resources for shelter and safety ensures the victim's immediate protection and access to support, addressing the urgent need for security.
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Which nursing action is most appropriate at this time?
- A. Criticize the nature of the client's rude behavior.
- B. Support the emaciated client who was targeted by the remark.
- C. Invite others in the group to respond to the situation.
- D. Embarrass the bulimic client with a similar comment.
Correct Answer: B
Rationale: Supporting the targeted client validates their feelings and maintains a safe group environment, addressing the immediate emotional impact.
The nurse is teaching the client with a substance abuse disorder about 12-step self-help programs such as AA. The nurse informs the client that the major principle associated with this 12-step program is what principle?
- A. Substance abuse disorders can be cured with total abstinence.
- B. Normal substance use can resume with the guidance and support of others.
- C. Acceptance of powerlessness over a substance is the first step in recovery.
- D. Substance abuse is a weakness that can be overcome through a belief in God.
Correct Answer: C
Rationale: AA’s first step is admitting powerlessness (C). Addiction is a disease not curable (A) or resumable (B) and not a weakness; higher power is personal (D).
When a client with dementia says, 'I want to go home,' which response by the nurse is most appropriate?
- A. You are at home.
- B. You are staying here.
- C. You must be homesick.
- D. You need to call your family.
Correct Answer: C
Rationale: Acknowledging homesickness validates the client's feelings, redirecting the conversation therapeutically without causing distress.
When the depressed client is scheduled for a series of electroconvulsive therapy (ECT) treatments, which reaction is most likely to be manifested in the immediate recovery period?
- A. A brief period of absence seizures
- B. Sensitivity to light and double vision
- C. Short-term memory loss and headaches
- D. Periods of unexplained fear and anxiety
Correct Answer: C
Rationale: Short-term memory loss and headaches are common post-ECT effects due to temporary brain disruption.
The client is hospitalized after sustaining a head injury and a fractured wrist from a fall. The client admits to drinking alcohol in moderation several times per week. Which assessment finding should the nurse associate with early alcohol withdrawal?
- A. Agitation
- B. Somnolence
- C. Slightly elevated BP
- D. Delirium tremens (DTs)
Correct Answer: C
Rationale: Slight BP elevation (C) is an early withdrawal sign. Agitation and DTs (A D) occur later somnolence (B) is unrelated.