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A client who is at risk for suicide following their partner's death is speaking with a nurse. Which of the following statements should the nurse make?
- A. "I feel very sorry for the loneliness you must be experiencing."
- B. "Suicide is not the appropriate way to cope with loss."
- C. "Losing someone close to you must be very upsetting."
- D. "I know how difficult it is to lose a loved one."
Correct Answer: C
Rationale: When a client is at risk for suicide, it is crucial for the nurse to acknowledge the emotional impact of losing a loved one without downplaying or judging their feelings. Statement C demonstrates empathy and understanding without making assumptions or providing unsolicited advice, making it the most appropriate response in this situation. Choice A focuses more on the nurse's feelings rather than the client's, which might not effectively address the client's emotional state. Choice B is judgmental and dismissive, which could further isolate the client. Choice D, although empathetic, shifts the focus to the nurse's experience rather than validating the client's feelings.
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A client has a new prescription for disulfiram for the treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example of?
- A. Aversion therapy
- B. Flooding
- C. Biofeedback
- D. Dialectical behavior therapy
Correct Answer: A
Rationale: Aversion therapy is a form of behavioral therapy that aims to create a negative response to a stimulus, in this case, alcohol consumption. Disulfiram is used in aversion therapy to induce unpleasant effects when alcohol is consumed, such as nausea and vomiting, to deter the individual from drinking. Therefore, the use of disulfiram in this context exemplifies aversion therapy. Flooding involves exposing an individual to a feared object or situation to overcome anxiety; biofeedback teaches self-regulation techniques, and dialectical behavior therapy is a type of cognitive-behavioral therapy focusing on acceptance and change strategies, which are not directly related to the use of disulfiram for alcohol use disorder.
A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?
- A. Personal space
- B. Posture
- C. Eye contact
- D. Intonation
Correct Answer: D
Rationale: Verbal communication involves the use of words, tone, and pitch to convey messages. Intonation refers to the variation of pitch in speech, which can convey emotions, attitudes, and emphasize certain points. Therefore, intonation is a key component of verbal communication, making it the correct choice in this scenario. Choices A, B, and C are aspects of nonverbal communication. Personal space, posture, and eye contact are important nonverbal cues that contribute to effective communication, but they are not components of verbal communication.
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention?
- A. Educating clients on health promotion techniques to reduce the risk of depression
- B. Performing screenings for depression at community health programs
- C. Establishing rehabilitation programs to decrease the effects of depression
- D. Providing support groups for clients at risk for depression
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client tells a nurse, 'Don't tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?
- A. Keep the client's communication confidential, but talk to the client daily using therapeutic communication to convince them to admit to hiding the knife
- B. Keep the client's communication confidential, but watch the client and their roommate closely
- C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others
- D. Report the incident to the health care team but do not inform the client of the intention to do so
Correct Answer: C
Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.
A client in an acute mental health facility is being discharged and requires supervision due to a severe mental illness. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care?
- A. Receiving daily care from a home health aide
- B. Having a weekly visit from a nurse case worker
- C. Attending a partial hospitalization program
- D. Visiting a community mental health center on a daily basis
Correct Answer: C
Rationale: For clients requiring supervision due to severe mental illness, attending a partial hospitalization program provides structured care and support while allowing the client to return home in the evenings, making it a suitable option for follow-up care. The other choices are less appropriate: A home health aide may not provide the necessary level of care and supervision, a weekly visit from a nurse case worker may not be sufficient for the client's needs, and visiting a community mental health center on a daily basis may not offer the structured support required for someone with a severe mental illness.