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A Native American patient describes a difficult childhood and dropping out of high school. The patient abused alcohol as a teenager to escape feelings of isolation but stopped 10 years ago. The patient now says,I feel stupid. Ive never had a good job. I dont help my people. Which nursing diagnosis applies?
- A. Risk for other-directed violence
- B. Deficient knowledge
- C. Chronic low self-esteem
- D. Social isolation
Correct Answer: B
Rationale: The patient has given several indications of chronic low self-esteem. Forming a positive self-image is often difficult for Native American individuals because these indigenous people must blend together both American and Native American worldviews. No defining characteristics are present for the other nursing diagnoses.
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Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide?
- A. It is required by the law by the federal government and in most states in the union.
- B. It is the nurse's professional responsibility to keep safety needs first and foremost.
- C. This is commonly required documentation for every encounter with every client.
- D. It allows the nurse to gain valuable experience in these kind of difficult discussions.
Correct Answer: B
Rationale: It is the nurse's professional responsibility to keep the client's safety needs first and foremost, and this includes overcoming any personal discomfort in talking about suicide. This is not required by any laws nor is it commonly required documentation for every encounter with every client. The nurse needs to gain experience in these kind of difficult discussions, but that is not a compelling reason for the nurse to discuss it if not warranted.
A client grieving the recent loss of her husband asks if she is becoming mentally ill because she is so sad. The nurse's best response would be,
- A. You may have a temporary mental illness because you are experiencing so much pain.
- B. You are not mentally ill. This is an expected reaction to the loss you have experienced.
- C. Were you generally dissatisfied with your relationship before your husband's death?
- D. Try not to worry about that right now. You never know what the future brings.
Correct Answer: B
Rationale: Mental illness includes general dissatisfaction with self, ineffective relationships, ineffective coping, and lack of personal growth. Additionally, the behavior must not be culturally expected. Acute grief reactions are expected and therefore not considered mental illness. False reassurance or overanalysis does not accurately address the client's concerns.
A patient is diagnosed with anorexia nervosa. The history reveals the patient virtually stopped eating 5 months ago and lost 25% of body weight. A nurse tells the patient, 'Describe what you think about your present weight and how you think you look.' Which response would be most consistent with the diagnosis?
- A. I’m fat and ugly.'
- B. What I think about myself is my business.'
- C. I’m grossly underweight, but thin is interesting.'
- D. I’m a few pounds overweight, but I can live with it.'
Correct Answer: A
Rationale: Anorexia nervosa involves a distorted body image; 'I’m fat and ugly' (Option A) reflects this denial of thinness despite a 25% weight loss. Option B avoids the question, C acknowledges thinness (atypical), and D underestimates the severity.
During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient’s hand. Select the correct analysis of the nurse’s behavior.
- A. It shows empathy and compassion. It will encourage the patient to continue to express feelings.
- B. The gesture is premature. The patient’s cultural and individual interpretation of touch is unknown.
- C. The patient will perceive the gesture as intrusive and overstepping boundaries.
- D. The action is inappropriate. Psychiatric patients should not be touched.
Correct Answer: B
Rationale: Touch requires cultural and individual assessment, as in Option B, to avoid misinterpretation. Options A, C, and D assume outcomes or overgeneralize without evidence.
A nurse assesses a confused older adult. The nurse experiences sadness and reflects, 'This patient is like one of my grandparents "¦ so helpless.' Which response is the nurse demonstrating?
- A. Transference
- B. Countertransference
- C. Catastrophic reaction
- D. Defensive coping reaction
Correct Answer: B
Rationale: Countertransference is the nurse's transference or response to a patient that is based on the nurse's unconscious needs, conflicts, problems, or view of the world. See relationship to audience response question.