Nokea
A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain to the spouse the etiology of this fear?
- A. Your spouse may be unable to resolve internal conflicts, which result in projected anxiety.
- B. Your spouse may be experiencing a distorted and unrealistic appraisal of the situation.
- C. Your spouse may have a genetic predisposition to overreacting to potential danger.
- D. Your spouse may have high levels of brain chemicals that may distort thinking.
Correct Answer: B
Rationale: The correct answer is B: Your spouse may be experiencing a distorted and unrealistic appraisal of the situation. This aligns with cognitive theory, which focuses on how our thoughts and perceptions influence our emotions and behaviors. In this case, the client's fear of the cruise ship sinking is likely based on an irrational and exaggerated belief rather than a realistic assessment of the situation.
Choice A is incorrect because it focuses on internal conflicts, which may not be directly related to the client's fear of the cruise ship sinking. Choice C is incorrect as genetic predisposition alone is unlikely to explain the specific fear of the cruise ship sinking. Choice D is incorrect as it suggests a biological basis for the fear, whereas cognitive theory emphasizes the role of thoughts and perceptions.
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An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
- A. The employee assertively confronts the boss
- B. The employee leaves the staff meeting to work out in the gym
- C. The employee criticizes a coworker
- D. The employee takes the boss out to lunch
Correct Answer: C
Rationale: Displacement is a defense mechanism where emotions are redirected from the original source to a substitute target. In this case, the employee is likely to displace their anger from the boss onto a coworker by criticizing them. This behavior allows the employee to express their feelings indirectly.
A: Assertively confronting the boss does not align with displacement as it involves direct confrontation.
B: Leaving the meeting to work out in the gym is a form of avoidance and does not involve displacing emotions onto another target.
D: Taking the boss out to lunch is more of a conciliatory gesture and does not involve displacing negative emotions onto someone else.
A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
- A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
- B. I wont stop taking this medication abruptly, because there could be serious complications.
- C. I will not drink alcohol while taking this medication.
- D. I wont take extra doses of this drug because I can become addicted.
Correct Answer: A
Rationale: The correct answer is A because the statement indicates a misunderstanding. Benzodiazepines do not require routine blood monitoring for toxicity. Benzodiazepines are typically monitored based on clinical response and potential side effects. Choices B, C, and D are all correct statements related to benzodiazepine use, emphasizing the importance of not abruptly stopping the medication, avoiding alcohol, and not taking extra doses to prevent addiction.
Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
In the role of milieu manager, which activity should the nurse prioritize?
- A. Setting the schedule for the daily unit activities
- B. Evaluating clients for medication effectiveness
- C. Conducting therapeutic group sessions
- D. Searching newly admitted clients for hazardous objects
Correct Answer: D
Rationale: The correct answer is D, searching newly admitted clients for hazardous objects. As a milieu manager, ensuring the safety of clients is a top priority. Searching for hazardous objects upon admission is crucial to prevent harm. Setting schedules (A) can be important but not as urgent as ensuring safety. Evaluating medication effectiveness (B) is important but not the primary role of a milieu manager. Conducting group sessions (C) is valuable for therapy but ensuring physical safety takes precedence.
When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate?
- A. Decreased resistance to disease
- B. Increased libido
- C. Decreased blood pressure
- D. Increased inflammatory response
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to disease. Prolonged stress can weaken the immune system, making individuals more susceptible to illnesses. Chronic stress suppresses immune functions, leading to decreased resistance to diseases. The other choices are incorrect because increased libido (B) and decreased blood pressure (C) are not typical physiological effects of sustained stress. While stress can lead to increased inflammatory response (D), the primary concern with chronic stress is its negative impact on the immune system, making choice A the most appropriate answer in this context.