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A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed
- B. Relax and reduce the amount of effort to solve the problem
- C. Shift attention from self to the needs and requests of others
- D. Focus on small achievable tasks, not taxing problems
Correct Answer: D
Rationale: Focusing on small achievable tasks promotes a sense of accomplishment, counteracting helplessness and supporting behavioral activation for depression. Ventilating emotions may not address avoidance. Reducing effort may worsen helplessness. Shifting attention to others does not directly address depressive symptoms.
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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?
- A. Involve client in daily exercise program
- B. Ask the client to describe her depression
- C. Spend time sitting in silence with client
- D. Observe for signs of possible psychosis
Correct Answer: C
Rationale: Spending time sitting in silence with the client provides a supportive presence without pressure for immediate responses, which is helpful for depression-related delays in communication. Exercise may be beneficial but does not address delayed responses directly. Asking about depression is useful for assessment but not immediate needs. Observing for psychosis is not indicated unless other symptoms are present.
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 client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?
- A. Responds with illogical answers to questions
- B. Admits to frequently thinking about committing suicide
- C. Describes times of depression followed by feelings of euphoria
- D. Exhibits compulsive, ritualistic behaviors
Correct Answer: A
Rationale: Responding with illogical answers indicates disorganized thinking, a hallmark of schizophrenia during psychosis. Suicide thoughts are not specific to schizophrenia. Depression and euphoria suggest bipolar disorder. Compulsive behaviors are more typical of OCD.
A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?
- A. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol
- B. Take the medication with at least 8 ounces (240 mL) of water and limit alcohol consumption while taking this medication
- C. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol
- D. Take the medication each morning beginning 48 hours after your last drink of alcohol
Correct Answer: D
Rationale: Disulfiram must be started at least 48 hours after the last alcohol intake to prevent severe reactions, and alcohol must be completely avoided. Options A and B incorrectly suggest limited alcohol is safe. Option C risks reactions if alcohol is still in the system.