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A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?
- A. "Perhaps you should discuss this with your physician."
- B. "Of course you aren't going to die, at least not in the immediate future."
- C. "I recommend you exercise daily and avoid smoking to decrease your risk."
- D. "Tell me more about these fears of dying from a heart attack."
Correct Answer: D
Rationale: Encouraging the client to talk about their fears fosters therapeutic communication.
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A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. "My parents treat me like a baby sometimes."
- B. "I haven't gotten my period yet, and all my friends have theirs."
- C. "None of the kids at this school like me, and I don't like them either."
- D. "There's a big pimple on my face, and I worry that everyone will notice it."
Correct Answer: C
Rationale: The correct answer is C. The nurse's priority should be to address the adolescent's statement about not liking any kids at school and feeling disliked by others. This suggests potential social isolation, which can impact mental health and well-being. Addressing social relationships is crucial at this age for emotional development. Choices A, B, and D are important but not urgent concerns. Choice A relates to family dynamics, B to physical development, and D to self-image; while these are valid issues, they do not have immediate implications for the adolescent's well-being like the social isolation expressed in choice C.
A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse’s priority response?
- A. "Do you really think your family would be better off without you?"
- B. "Tell me what is happening right now."
- C. "Have you thought of harming yourself?"
- D. "When did you first start feeling this way?"
Correct Answer: C
Rationale: The correct answer is C: "Have you thought of harming yourself?" because it addresses the immediate safety concern of suicidal ideation. It is crucial to assess the client's risk of self-harm or suicide first. Choice A is not a direct inquiry about self-harm. Choice B focuses on the current situation but does not address the suicidal statement. Choice D is more about exploring the history of depressive symptoms rather than assessing immediate risk.
A nurse is reviewing medication records for several psychiatric clients who have bipolar disorder. Which of the following medications is commonly used to treat bipolar disorder?
- A. Paroxetine
- B. Lithium
- C. Donepezil
- D. Valproate
- E. Carbamazepine
Correct Answer: B
Rationale: The correct answer is B: Lithium. Lithium is a mood stabilizer commonly used to treat bipolar disorder by reducing the frequency and intensity of manic episodes. It helps to balance neurotransmitters in the brain. Paroxetine (A) is an antidepressant, Donepezil (C) is used for Alzheimer's disease, Valproate (D) is another mood stabilizer, and Carbamazepine (E) is an anticonvulsant often used in bipolar disorder. Therefore, the correct choice is Lithium (B) as it specifically targets bipolar symptoms.
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
- A. Denial
- B. Displacement
- C. Projection
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of "I'm fine" despite having traumatic injuries indicate a defense mechanism of denial, where the client is refusing to acknowledge the severity of their situation. Denial helps the individual cope with overwhelming emotions or stress by avoiding the reality of the situation. Displacement involves redirecting emotions to a less threatening target, projection involves attributing one's thoughts or feelings to others, and undoing involves engaging in behaviors to counteract negative thoughts or actions. In this scenario, denial is the most appropriate reaction based on the client's behavior.
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, 'I don't know what I will do if they find I have cancer.' Which of the following responses should the nurse make?
- A. Why do you think you might have cancer when your diagnosis is a benign condition?'
- B. I'm looking at your chart here and I don't see any reason for you to worry about that.'
- C. I think that's something you need to discuss with your provider.'
- D. I'm hearing that you are concerned that it might turn out that you have cancer.'
Correct Answer: D
Rationale: Rationale: The correct response is D because it acknowledges the client's fear and validates their emotions. By reflecting back the client's statement, the nurse shows empathy and understanding. This approach helps build trust and rapport with the client, fostering open communication. Choice A is dismissive and does not address the client's feelings. Choice B is invalidating and can increase the client's anxiety. Choice C deflects the client's emotions instead of addressing them directly. In summary, option D is the best response as it demonstrates active listening and empathy, promoting a therapeutic nurse-client relationship.