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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.
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A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
- A. Helping the client identify positive personality traits
- B. Providing for adequate hydration and rest
- C. Confronting the use of denial and other defense mechanisms
- D. Educating the client about the consequences of alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing for adequate hydration and rest. The priority in caring for a client with alcohol use disorder is addressing physical needs like hydration and rest to manage withdrawal symptoms and prevent complications. Hydration helps prevent dehydration and electrolyte imbalances, while rest supports the body's healing process. Choices A, C, and D focus on psychological aspects, which are important but secondary to addressing immediate physical needs. Helping the client identify positive traits can come later in therapy, confronting denial and defense mechanisms can be addressed once the client is stabilized, and educating about consequences is important but not as urgent as ensuring hydration and rest.
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
- A. Inform the client of consequences.
- B. Speak slowly in a low, calm voice.
- C. Forbid the client from speaking in an abusive manner.
- D. Remain a distance of 1 ft away from the client.
Correct Answer: B
Rationale: Speaking calmly helps de-escalate aggression.
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following actions should be included in the plan of care?
- A. Allow manipulation so as to not raise the client’s anxiety.
- B. Avoid discussing past behaviors with the client.
- C. Bargain with the client to discourage manipulative behavior.
- D. Set clear and consistent limits on manipulative behaviors.
Correct Answer: D
Rationale: The correct answer is D: Set clear and consistent limits on manipulative behaviors. By setting clear boundaries, the nurse establishes a structured environment that promotes accountability and helps the client understand appropriate behavior. This method reinforces boundaries and helps the client learn to interact in a healthier way.
Explanation for other choices:
A: Allowing manipulation does not address the underlying issue and may enable further manipulative behavior.
B: Avoiding discussing past behaviors hinders the therapeutic process and may prevent understanding and resolution of manipulative tendencies.
C: Bargaining with the client only reinforces manipulative behavior and does not address the root cause.
In summary, setting clear and consistent limits is the most effective approach in managing manipulative behavior.
A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
- A. Honk the car horn to get the client's attention.
- B. Calmly speak the client's name out of the car window.
- C. Keep driving in a path that is going away from the client's house.
- D. Stop the car in the client's driveway and call the authorities.
Correct Answer: C
Rationale: Leaving the situation and seeking help from authorities is the safest course of action.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.