Nokea
A client is diagnosed with somatic symptom disorder. Which question will help the nurse develop nursing diagnoses for this client's plan of care?
- A. Are you satisfied with your appearance?
- B. Do you take medication for anxiety as prescribed?
- C. When did you last feel detached from your environment?
- D. How long have you had these memory problems?
Correct Answer: B
Rationale: In clients with somatic symptom disorder, it is crucial to assess their adherence to medication for anxiety as prescribed. This question helps the nurse understand the client's treatment compliance, which can impact the development of nursing diagnoses and the overall plan of care. Monitoring medication adherence is essential in managing the client's symptoms and improving outcomes.
You may also like to solve these questions
A 10-year-old boy breaks his mother's vase while playing. When the mother asks who broke the vase, the little boy says that his sister did it. The little boy is exhibiting which defense mechanism?
- A. Projection
- B. Displacement
- C. Dissociation
- D. Sublimation
Correct Answer: A
Rationale: Projection is a defense mechanism where one attributes their own unacceptable thoughts, feelings, or impulses onto another person. In this scenario, the little boy is projecting his actions onto his sister by falsely claiming she broke the vase. Displacement involves transferring emotions from the original source to a substitute target. Dissociation is a disconnection between thoughts, identity, consciousness, and memory. Sublimation is the redirection of unacceptable impulses into socially acceptable activities.
A client diagnosed with OCD spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?
- A. Dissociation
- B. Rationalization
- C. Sublimation
- D. Intellectualization
Correct Answer: D
Rationale: Intellectualization is a defense mechanism where an individual focuses on rational, logical explanations to distance themselves from uncomfortable emotions. In this scenario, the client discusses the OCD rituals in a detailed and analytical manner, avoiding the emotional aspects associated with them. This behavior reflects intellectualization rather than dissociation, rationalization, or sublimation. Dissociation involves a disconnection from reality, rationalization is the attempt to justify behaviors, and sublimation is redirecting unacceptable impulses into socially acceptable activities.
The client recently survived a plane crash and is assessed by the nurse. Which client statement would cause the nurse to suspect that the client may be experiencing PTSD?
- A. I believe that I was meant to survive this accident so that I can focus on the important things in life
- B. Although I have nightmares sometimes, I have started going to church to show gratitude for surviving the crash
- C. I am so afraid that I will never be able to fly again, but I know that it will take a while
- D. I keep having these thoughts about the crash that just pop into my mind at random times
Correct Answer: D
Rationale: Experiencing intrusive thoughts about a traumatic event, such as a plane crash, that occur unexpectedly and repeatedly is a common symptom of Post-Traumatic Stress Disorder (PTSD). These thoughts can be distressing and are often a key indicator of PTSD. Options A, B, and C demonstrate coping mechanisms and fears related to the traumatic event but do not specifically address the hallmark symptom of intrusive thoughts. Therefore, option D is the correct choice as it aligns with a potential symptom of PTSD.
In what significant way should the therapeutic environment differ for a client who has ingested LSD from that of a client who has ingested PCP?
- A. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation. For PCP ingestion, place client on one-on-one intensive supervision.
- B. For LSD ingestion, place the client in restraints. For PCP ingestion, place the client on seizure precautions.
- C. For LSD ingestion, provide continual medieval simulation involving as many senses as possible. For PCP ingestion, provide continual high-level stimulation.
- D. For PCP ingestion, place the client on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.
Correct Answer: D
Rationale: When managing a client who has ingested PCP, it is crucial to provide one-on-one intensive supervision to ensure their safety and prevent any harm to themselves or others. This level of supervision is necessary due to the unpredictable and potentially dangerous effects of PCP. On the other hand, for a client who has ingested LSD, it is recommended to maintain a calm environment with limited interaction and minimal verbal stimulation. This approach aims to prevent exacerbating any adverse effects of LSD, such as anxiety or paranoia, by reducing external stimuli. Therefore, the correct approach is to provide one-on-one intensive supervision for PCP ingestion and limit interaction and verbal stimulation for LSD ingestion.
A nursing instructor is teaching a group of students about intimate partner violence. Which response by the students indicates no further teaching is needed?
- A. Alaska Native women report the highest rate of intimate partner violence.
- B. Caucasian women report the lowest rate of intimate partner violence.
- C. African American women report the highest rate of intimate partner violence.
- D. Asian women report the lowest rate of intimate partner violence.
Correct Answer: A
Rationale: The correct answer is A. Alaska Native women do report the highest rate of intimate partner violence. This statistic is important for healthcare professionals to be aware of to provide culturally sensitive care and interventions. Choices B, C, and D are incorrect statements. While it is essential to understand disparities in intimate partner violence rates among different populations, in this context, the focus is on recognizing the accurate information provided about Alaska Native women.