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A client on a psychiatric unit says,"It's a waste of time to be here. I can't talk to you or anyone." Which would be an appropriate therapeutic nursing response?
- A. "I find that hard to believe."
- B. "Are you feeling that no one understands?"
- C. "I think you should calm down and look on the positive side."
- D. "Our staff here is excellent, and you are in good hands."
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and encourages the client to express their feelings. By asking if the client feels that no one understands, the nurse acknowledges the client's emotions and opens the door for further discussion. Choice A is confrontational and may make the client defensive. Choice C dismisses the client's feelings and is not validating. Choice D is a vague reassurance that does not address the client's concerns.
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The statement"Growth involves resolution of critical tasks through the eight stages of the life cycle" is a concept of which therapeutic model?
- A. Interpersonal.
- B. Cognitive-behavioral.
- C. Intrapersonal.
- D. Psychoanalytic.
Correct Answer: A
Rationale: The correct answer is A: Interpersonal. This concept aligns with Erikson's psychosocial theory, which emphasizes the importance of resolving developmental tasks at each stage of life. Interpersonal therapy focuses on relationships and interactions with others, making it the most suitable model for addressing growth through the life cycle. Choice B (Cognitive-behavioral) focuses on thoughts and behaviors, not developmental stages. Choice C (Intrapersonal) refers to self-awareness and understanding, not specifically addressing life stages. Choice D (Psychoanalytic) focuses on unconscious processes and early childhood experiences, not necessarily on resolving tasks through different life stages.
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
- A. Use of substances 6 hours before the assessment
- B. Speech patterns
- C. Availability of support resources
- D. Amount of sleep in past 24 hours
Correct Answer: A
Rationale: The correct answer is A: Use of substances 6 hours before the assessment. This is important to assess as substance use can increase the risk of impulsive behavior and exacerbate suicidal thoughts. It is crucial to determine if the individual has recently used substances as it may impact their judgment and decision-making. The other choices are not directly related to immediate risk assessment for suicide. Speech patterns (B) may provide insight into the individual's mental state, but substance use takes precedence in assessing immediate risk. Availability of support resources (C) is important for long-term prevention but does not address immediate risk. The amount of sleep in the past 24 hours (D) may impact mental health but does not directly assess immediate risk of suicide.
Which individual is demonstrating the highest level of resilience?
- A. Is able to repress stressors.
- B. Becomes depressed after the death of a spouse.
- C. Lives in a shelter for 2 years after the home is destroyed by fire.
- D. Takes a temporary job to maintain financial stability after loss of a permanent job.
Correct Answer: D
Rationale: The correct answer is D because the individual demonstrates resilience by adapting to adversity and taking proactive steps to maintain financial stability after a setback. This shows a positive coping mechanism and ability to bounce back.
A is incorrect as repressing stressors is not a healthy way of dealing with challenges. B is incorrect as becoming depressed indicates a lack of resilience. C, although a challenging situation, does not necessarily indicate the highest level of resilience as the individual is not actively taking steps to improve their situation.
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
A patient whose history includes experiences with abusive partners is being treated for major depressive disorder. The patient's care plan includes rape-trauma syndrome among its nursing diagnoses. What goal is directly associated with this diagnosis?
- A. Remains free from self-harm
- B. Wears appropriate clothing
- C. Reports feeling stronger and having a sense of hopefulness
- D. Demonstrates appropriate affect for both positive and negative emotions
Correct Answer: C
Rationale: The correct answer is C: Reports feeling stronger and having a sense of hopefulness. This goal is directly associated with rape-trauma syndrome as it focuses on the patient's emotional healing and empowerment. By reporting feeling stronger and having hope, the patient is demonstrating progress towards recovery from the trauma. Choice A is incorrect because remaining free from self-harm is more related to monitoring safety rather than addressing the emotional impact of the trauma. Choice B is irrelevant as wearing appropriate clothing does not directly address the emotional healing process. Choice D is incorrect as demonstrating appropriate affect does not specifically target the psychological aspect of overcoming trauma.