Nokea
A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?
- A. Ignore the nonverbal behavior and focus on the client's verbal messages
- B. Integrate the verbal and nonverbal messages and interpret them as one
- C. Ask the client's spouse to interpret the discrepancy
- D. Pay close attention and document the nonverbal messages
Correct Answer: D
Rationale: Paying close attention and documenting nonverbal messages gathers comprehensive data for further exploration. Ignoring nonverbal cues misses important information. Integrating messages prematurely may misinterpret the discrepancy. Asking the spouse to interpret is inappropriate and may not be accurate.
You may also like to solve these questions
What symptoms are consistent with long-term rape trauma? Select all that apply.
- A. Social withdrawal
- B. Exaggerated startle response
- C. Intrusive thoughts
- D. Avoidance of places associated with the assault
Correct Answer: A,B,C,D
Rationale: A: Social withdrawal reflects ongoing distress. B: Exaggerated startle response persists post-trauma. C: Intrusive thoughts are unwanted trauma-related memories. D: Avoidance of trauma-associated places is a protective mechanism. All are hallmark long-term symptoms of rape-trauma syndrome.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Ask the client to describe and identify the source of the feelings
- B. Provide education about ways to cope with anxiety
- C. Assist the client with relaxation techniques in the group
- D. Escort the client from the group to reduce stimuli
Correct Answer: C
Rationale: Assisting the client with relaxation techniques in the group is the best intervention as it provides immediate support and can help alleviate the client's anxiety in the moment. Exploring the source of anxiety may not be suitable during a group session where immediate relief is needed. Education on coping mechanisms is valuable but does not address immediate needs. Escorting the client out may be considered if anxiety becomes overwhelming, but it is secondary to attempting in-group relaxation.
A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?
- A. Current vital signs
- B. White blood cell count
- C. 24-hour urinary output
- D. Blood sugar level
Correct Answer: A
Rationale: Current vital signs are critical for assessing NMS, a life-threatening side effect of haloperidol, indicated by fever, unstable blood pressure, and tachycardia. White blood cell count, urinary output, and blood sugar are less specific to NMS.
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.
A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?
- A. I understand that you're angry and unhappy. Let's explore ways in which you overreact
- B. I hear your frustration about losing control. Tell me how this affects your daily life
- C. Knowing the cause of your symptoms will make them easier to handle
- D. Do all that you can to learn all that you can while you are here. You can get better
Correct Answer: B
Rationale: This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship. The first option may invalidate feelings by assuming overreaction. The third shifts focus from immediate concerns. The fourth is encouraging but does not address current feelings.