Nokea
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.
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The client has developed paranoia as a result of regular methamphetamine use. The nurse uses cognitive reappraisal to confront the client’s persecutory thoughts. Which question should the nurse ask the client?
- A. “How can you look at this differently?”
- B. “Why would they want to cause you harm?”
- C. “What did you do that makes others not like you?”
- D. “How do you feel when others create problems for you?”
Correct Answer: A
Rationale: Reappraisal via alternative perspectives (A) aids restructuring. “Why” (B) or blame (C) reinforce distortion feelings (D) aren’t cognitive.
The experienced nurse determines that the new nurse’s actions are therapeutic when managing the cognitively impaired client whose agitated behavior is escalating. Which nursing actions should have occurred? Select all that apply.
- A. Saying “Mr. Smith will you look at me please?”
- B. Saying “You seem upset. How can I help you?”
- C. Presenting the client with detailed expectations.
- D. Turning off the television in the room to decrease noise.
- E. Saying “Getting so angry will not help you get what you want.”
- F. Saying “Speaking as loud as the client to ensure that the client hears what is being said.”
Correct Answer: A ,B, D
Rationale: Using the client’s name (A) acknowledging upset (B) and reducing stimuli (D) calm agitation. Detailed expectations (C) challenging anger (E) or loud speech (F) may escalate.
Which clients are most likely to be members of an obsessive-compulsive disorder (OCD) support group? Select all that apply.
- A. A 30-year-old who performs handwashing five times per hour
- B. A 35-year-old who wears gloves when touching a public faucet
- C. A 40-year-old who is sexually promiscuous
- D. A 45-year-old who drinks a fifth of whiskey daily
- E. A 50-year-old who cannot throw anything away
- F. A 60-year-old who repeatedly checks the locks on locked doors
Correct Answer: A,B,E,F
Rationale: Compulsive handwashing, glove-wearing, hoarding, and lock-checking are characteristic OCD behaviors involving repetitive actions to reduce anxiety.
The nurse is planning care for the client who has a cognitive deficit and a history of violence following head trauma. What is the primary effect of a cognitive deficit that can contribute to the client having a catastrophically violent reaction?
- A. The client’s ability to process information including instructions is limited.
- B. The client has a decreased ability to interpret and tolerate sensory stimuli.
- C. The staff has a more difficult time providing appropriate milieu boundaries.
- D. The staff’s attention is oftentimes diverted to other more manipulative clients.
Correct Answer: B
Rationale: Decreased ability to tolerate sensory stimuli (B) triggers catastrophic reactions. Processing (A) boundaries (C) and staff attention (D) are not primary contributors.
The nurse educator is orienting new nursing staff to the behavioral care unit when one nurse asks “How will I know which clients are potentially violent?” Which response by the nurse educator is best?
- A. “Just be alert and aware of your client’s behavioral clues.”
- B. “The client prone to violence will usually tell you they are angry about something.”
- C. “As you plan care review the clients’ charts to determine who has a history of violence.”
- D. “Your orientation will include an in-service on violent clients and how to identify them.”
Correct Answer: C
Rationale: Reviewing charts for violence history (C) identifies risk as history and impulsivity predict violence. Vague alertness (A) verbal cues (B) or delayed training (D) are less effective.