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A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?
- A. "Everyone feels better after showering."
- B. "You must be getting better. You look great!"
- C. "I see you have done some grooming today."
- D. "Why are you all dressed up today? Is it a special occasion?"
Correct Answer: C
Rationale: A neutral, observational statement acknowledges the client’s effort without assuming improvement.
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A nurse is caring for a client who has an eating disorder. The nurse is practicing which of the following ethical concepts when the client refuses to drink a between-meal protein and calorie supplement?
- A. Autonomy
- B. Beneficence
- C. Veracity
- D. Fidelity
Correct Answer: A
Rationale: Respecting the client’s decision to refuse food aligns with the ethical principle of autonomy.
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)
- A. Anxiety
- B. Obsessive-compulsive disorder
- C. Schizophrenia
- D. Breathing-related sleep disorder
- E. Depression
Correct Answer: A, B, E
Rationale: Anxiety, OCD, and depression frequently co-occur with eating disorders.
A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?
- A. Being married
- B. Pregnancy
- C. Male gender
- D. Chronic illness
Correct Answer: D
Rationale: The correct answer is D: Chronic illness. Chronic illnesses can lead to feelings of hopelessness and helplessness, contributing to the development of depression. Individuals facing long-term health challenges may experience significant emotional distress, impacting their mental health. Other choices are incorrect because being married (A) can provide social support, which is protective against depression; pregnancy (B) can lead to mood changes but is not a consistent risk factor for depression; and male gender (C) does not inherently increase the risk of depression as much as other factors.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
- A. Encouraging client feedback about satisfaction with the facility experience
- B. Explaining unit rules and policies regarding unacceptable behaviors
- C. Supporting the client’s wish to refuse prescribed medications
- D. Making sure the client understands expectations for participation
Correct Answer: C
Rationale: The correct answer is C: Supporting the client’s wish to refuse prescribed medications. Autonomy refers to the client's right to make their own decisions about their care. By supporting the client's wish to refuse medications, the nurse is respecting the client's autonomy and right to make decisions about their treatment. This empowers the client to have control over their own healthcare decisions.
Explanation for incorrect choices:
A: Encouraging client feedback about satisfaction with the facility experience - This choice relates to client satisfaction but does not directly address autonomy.
B: Explaining unit rules and policies regarding unacceptable behaviors - This choice focuses on rules and policies, not autonomy.
D: Making sure the client understands expectations for participation - This choice is about ensuring understanding, not necessarily autonomy.