Nokea
A couple in counseling reports fighting with their child when they are angry with each other. This behavior typifies:
- A. coalition.
- B. indirect communication.
- C. transference.
- D. triangulation.
Correct Answer: D
Rationale: Triangulation involves a third party (the child) being drawn into a conflict between two others (the parents) as a way to manage tension.
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The nursing role that involves being a substitute for another, such as a parent, is called
- A. Counselor
- B. Resource person
- C. Surrogate
- D. Teacher
Correct Answer: C
Rationale: The surrogate role in nursing involves temporarily acting as a substitute figure, like a parent, to meet the client's emotional needs.
When planning care for a client who has ingested phencyclidine (PCP), the nurse is aware that the following is the highest priority?
- A. Client's physical needs
- B. Client's safety needs
- C. Client's psychosocial needs
- D. Client's medical needs
Correct Answer: B
Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs are met, the client's physical, psychosocial, and medical needs can be met.
A nurse is interviewing an 8-year-old girl who was admitted to the pediatric unit. Which statement by the child needs to be explored?
- A. Wow! This place has bright colors.'
- B. Is my mother allowed to visit me tonight?'
- C. Those boys are so cute. I hope their room is next to mine?'
- D. I am scared about being here. Can you stay with me awhile?'
Correct Answer: D
Rationale: Expressing fear signals anxiety needing exploration, unlike curiosity (A, B) or social interest typical for this age.
A male client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?
- A. Vomiting, diarrhea, and bradycardia
- B. Dehydration, temperature above 101 F (38.3 C), and pruritus
- C. Hypertension, diaphoresis, and seizures
- D. Diaphoresis, tremors, and nervousness
Correct Answer: D
Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbances, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia—not bradycardia—is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101 F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.
When screening families for post-traumatic stress disorder following a major natural disaster, psychiatric-mental health nurses are practicing which type of disease prevention?
- A. Primary.
- B. Secondary.
- C. Tertiary.
- D. Universal.
Correct Answer: B
Rationale: Screening for PTSD after a disaster is secondary prevention, aimed at early detection and intervention to reduce severity.