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A client with major depressive disorder expresses feelings of hopelessness. Which nursing intervention should the nurse implement to address these feelings?
- A. Encourage the client to engage in physical activity.
- B. Provide opportunities for the client to make decisions.
- C. Help the client identify positive aspects of their life.
- D. Encourage the client to verbalize feelings of hopelessness.
Correct Answer: C
Rationale: When a client with major depressive disorder expresses feelings of hopelessness, helping them identify positive aspects of their life can be an effective nursing intervention. This approach can assist in shifting their focus from negativity to positivity, promoting a sense of hope and potentially improving their overall outlook and well-being. By highlighting the positive aspects, the nurse can support the client in recognizing reasons for hope and encourage a more optimistic perspective, which can aid in addressing and alleviating feelings of hopelessness. Encouraging physical activity (Choice A) may be beneficial for overall well-being but may not directly address feelings of hopelessness. Providing opportunities for decision-making (Choice B) can empower the client but may not specifically target feelings of hopelessness. Encouraging verbalization of feelings (Choice D) is important but may not be as effective as helping the client shift their focus to positive aspects of life.
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A client with a history of alcohol use disorder is admitted to the hospital. Which assessment finding would indicate early alcohol withdrawal?
- A. Bradycardia
- B. Hypotension
- C. Diaphoresis
- D. Hypothermia
Correct Answer: C
Rationale: In a client experiencing early alcohol withdrawal, one of the key assessment findings is diaphoresis (excessive sweating). This is due to autonomic hyperactivity commonly seen during this phase, along with other signs like tremors and tachycardia. Bradycardia (slow heart rate), hypotension (low blood pressure), and hypothermia (low body temperature) are not typically associated with early alcohol withdrawal, making them incorrect choices.
A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?
- A. Encourage the client to discuss the voices.
- B. Instruct the client to listen to music to drown out the voices.
- C. Tell the client that the voices are not real.
- D. Distract the client from the voices.
Correct Answer: A
Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia.
Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.
When preparing a teaching plan for a client with generalized anxiety disorder, which information should a healthcare professional include?
- A. Avoiding caffeine and other stimulants
- B. Engaging in regular physical activity
- C. Practicing relaxation techniques
- D. Keeping a journal of anxiety triggers
Correct Answer: C
Rationale: The correct answer is C: Practicing relaxation techniques. This is a crucial aspect of managing generalized anxiety disorder. Techniques like deep breathing, progressive muscle relaxation, and mindfulness can effectively reduce anxiety levels and promote calmness. These techniques provide valuable coping mechanisms to help individuals with generalized anxiety disorder deal with stress and anxiety.\nChoice A, avoiding caffeine and other stimulants, can be beneficial but is not as central to managing generalized anxiety disorder as practicing relaxation techniques.\nChoice B, engaging in regular physical activity, is also helpful for managing anxiety, but relaxation techniques are more specific and targeted for addressing symptoms of generalized anxiety disorder.\nChoice D, keeping a journal of anxiety triggers, may be a useful strategy to identify triggers but does not directly address the immediate management of anxiety symptoms, unlike practicing relaxation techniques.
Which client action is an example of the defense mechanism of reaction formation?
- A. A woman who feels unattractive constantly praises the looks of others.
- B. A man who feels insecure about his masculinity exaggerates his strength.
- C. A person who feels guilty about cheating accuses others of being unfaithful.
- D. A child who feels neglected tries to win approval from teachers.
Correct Answer: A
Rationale: The defense mechanism of reaction formation involves expressing the opposite of one's true feelings. In this case, the woman who feels unattractive praises the looks of others as a way to mask her own feelings of inadequacy. This behavior represents a form of overcompensation where the individual showcases an exaggerated opposite trait to conceal their true emotions. Choices B, C, and D do not align with reaction formation. Choice B describes compensation, where one overemphasizes a trait to make up for a perceived weakness. Choice C illustrates projection, where one attributes their feelings onto others. Choice D demonstrates a form of seeking attention or approval, which does not fit reaction formation.
A client is prescribed diazepam (Valium) for anxiety. Which statement by the client indicates a need for further teaching?
- A. I can drink alcohol while taking this medication.
- B. I should avoid drinking alcohol while taking this medication.
- C. I should take this medication only when I feel anxious.
- D. I can stop taking this medication when I feel better.
Correct Answer: A
Rationale: The correct answer is A because clients should avoid alcohol while taking diazepam (Valium) due to potential interactions. Alcohol can increase the sedative effects of diazepam, leading to excessive drowsiness or respiratory depression. Choice B is correct as it reflects the need to avoid alcohol. Choice C is incorrect because diazepam is usually taken regularly, not just when feeling anxious. Choice D is incorrect as abruptly stopping diazepam can lead to withdrawal symptoms and should be done gradually under medical supervision.