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A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate?
- A. Im confident you know whats best for you.
- B. This may not be the best time for you to make such an important decision.
- C. Your children will be terribly disappointed.
- D. Tell me why you want to make this change.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions and gently suggests caution in making a big decision during a vulnerable time. It shows empathy and encourages the client to reconsider the decision later. Choice A lacks exploration of client's feelings, Choice C introduces unnecessary guilt, and Choice D focuses on the change rather than the emotional state.
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To promote self-reliance, how should a psychiatric nurse best conduct medication administration?
- A. Encourage clients to request their medications at the appropriate times.
- B. Refuse to administer medications unless clients request them at the appropriate times.
- C. Allow the clients to determine appropriate medication times.
- D. Take medications to the clients bedside at the appropriate times.
Correct Answer: A
Rationale: The correct answer is A because it promotes self-reliance by empowering clients to take responsibility for their own medication schedule. By encouraging clients to request their medications at the appropriate times, the nurse fosters autonomy and self-management.
Choice B is incorrect as it is too extreme and may compromise client safety by withholding medications based solely on client request. Choice C is incorrect as it puts the responsibility solely on the client without appropriate guidance from the nurse. Choice D is incorrect as it does not actively involve the client in the medication administration process.
A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
- A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
- B. I wont stop taking this medication abruptly, because there could be serious complications.
- C. I will not drink alcohol while taking this medication.
- D. I wont take extra doses of this drug because I can become addicted.
Correct Answer: A
Rationale: The correct answer is A because the statement indicates a misunderstanding. Benzodiazepines do not require routine blood monitoring for toxicity. Benzodiazepines are typically monitored based on clinical response and potential side effects. Choices B, C, and D are all correct statements related to benzodiazepine use, emphasizing the importance of not abruptly stopping the medication, avoiding alcohol, and not taking extra doses to prevent addiction.
An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
- A. Encourage the student to use the alternative coping mechanism of relaxation exercises.
- B. Complete the problem-solving process for the client.
- C. Work through the problem-solving process with the client.
- D. Encourage the client to keep a journal.
Correct Answer: C
Rationale: The correct answer is C: Work through the problem-solving process with the client. This option promotes empowerment and autonomy by guiding the client to develop their problem-solving skills. It allows the nurse to offer support and guidance without taking over the process entirely, fostering independence and self-efficacy. Encouraging the client to actively participate in finding solutions can help build confidence and improve their ability to handle similar situations in the future.
Explanation for other choices:
A: Encouraging relaxation exercises can be helpful for managing anxiety, but it does not directly address the underlying issue of developing problem-solving skills.
B: Completing the problem-solving process for the client does not empower the client to learn how to address similar challenges independently.
D: Keeping a journal can be a helpful tool for self-reflection and managing emotions, but it does not specifically address the client's difficulty with independent problem-solving.
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.
A psychiatric nurse uses Sullivans theories in group and individual therapy. According to Sullivan and other theorists like him, how are client symptoms viewed behaviors that are maintained because they are reinforced?
- A. Client symptoms are viewed as responses to anxiety arising from interpersonal relationships.
- B. Client symptoms are viewed as internal conflicts arising from early childhood trauma.
- C. Client symptoms are viewed as the misinterpretations of experiences.
- D. Client symptoms are viewed as learned
Correct Answer: B
Rationale: The correct answer is B because Sullivan and other theorists like him believe that client symptoms are viewed as internal conflicts arising from early childhood trauma. Sullivan emphasized the impact of early relationships on personality development, suggesting that unresolved conflicts from childhood can manifest as symptoms in adulthood. This perspective aligns with psychodynamic theories that emphasize the role of unconscious processes and early experiences in shaping behavior.
Choice A is incorrect because it focuses on anxiety arising from interpersonal relationships, which is more aligned with interpersonal theories rather than Sullivan's emphasis on childhood experiences. Choice C is incorrect as it suggests misinterpretations of experiences, which does not fully capture the depth of internal conflicts highlighted by Sullivan. Choice D is incorrect as it simplifies client symptoms as learned behaviors without considering the underlying emotional conflicts rooted in early childhood experiences, as emphasized by Sullivan.