Nokea
A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive behavioral family therapy in response to which of the following client statements?
- A. I want to learn how to change the way I react to problems within my family
- B. I want to understand why my past experiences are affecting my family relationships
- C. I want to improve my family’s understanding of each other’s boundaries
- D. I want each of my family members to be more aware of each other’s feelings
Correct Answer: A
Rationale: The correct answer is A because cognitive behavioral family therapy focuses on changing negative thought patterns and behaviors. By wanting to change the way they react to family problems, the client is demonstrating a readiness to engage in cognitive restructuring and behavioral change. Choice B is incorrect as it pertains more to individual therapy exploring past experiences. Choice C is incorrect as it focuses on improving understanding of boundaries, which is not the primary goal of cognitive behavioral family therapy. Choice D is incorrect because it emphasizes awareness of feelings rather than addressing reactive behaviors.
You may also like to solve these questions
A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?
- A. Anhedonia
- B. Waxy flexibility
- C. Contractions of the jaw
- D. Incongruent affect
Correct Answer: C
Rationale: The correct answer is C: Contractions of the jaw. Thioridazine is an antipsychotic medication known to cause extrapyramidal side effects such as dystonia, which can manifest as contractions of the jaw. Anhedonia (A) is the inability to experience pleasure, not a side effect of thioridazine. Waxy flexibility (B) is a symptom of catatonia, not a side effect of thioridazine. Incongruent affect (D) refers to a mismatch between expression and emotion, not a side effect of thioridazine.
A nurse is assessing a client who has opioid intoxication. Which of the following findings should the nurse expect?
- A. Pinpoint pupils
- B. Hyperreflexia
- C. Increased respiratory rate
- D. Dilated pupils
Correct Answer: A
Rationale: The correct answer is A: Pinpoint pupils. Opioid intoxication causes miosis, resulting in constricted or pinpoint pupils. This occurs due to the suppression of the sympathetic nervous system. Hyperreflexia (B) is not typically associated with opioid intoxication; it is more common in conditions like spinal cord injury. Opioids depress the respiratory system, leading to decreased respiratory rate (C), not increased. Dilated pupils (D) are more indicative of stimulant intoxication, such as amphetamines.
A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take?
- A. Encourage the client to suppress feelings of trauma
- B. Assign the same staff to care for the client each day
- C. Address the client in an authoritative manner
- D. Limit the amount of time spent with the client
Correct Answer: B
Rationale: The correct answer is B: Assign the same staff to care for the client each day. Consistency in care providers helps establish trust and a sense of safety for clients with PTSD. This familiarity can reduce anxiety and improve therapeutic rapport. Encouraging the client to suppress feelings of trauma (A) can be harmful as it may worsen symptoms. Addressing the client in an authoritative manner (C) can trigger feelings of threat. Limiting time spent with the client (D) can hinder the development of a therapeutic relationship.
A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take?
- A. Withhold the next dose of lithium
- B. Repeat the lithium level test
- C. Administer the next dose of lithium
- D. Recommend a low sodium diet
Correct Answer: C
Rationale: The correct answer is C: Administer the next dose of lithium. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L), so the nurse should continue the medication as prescribed. Withholding the dose (choice A) can lead to subtherapeutic levels and ineffective treatment. Repeating the test (choice B) is unnecessary as the current level is within the therapeutic range. Recommending a low sodium diet (choice D) is not directly related to lithium therapy.
A nurse in a psychiatric unit is providing discharge teaching to a client who has major depressive disorder and a new prescription for fluoxetine. Which of the following instructions should the nurse include?
- A. Take the medication in the morning
- B. Expect improvement within 24 hours
- C. Discontinue the medication when symptoms improve
- D. Avoid foods high in tyramine
Correct Answer: A
Rationale: The correct answer is A: Take the medication in the morning. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression. Taking it in the morning helps prevent insomnia, a common side effect. Option B is incorrect as improvement may take weeks, not 24 hours. Option C is wrong as stopping abruptly can lead to withdrawal symptoms. Option D is irrelevant as tyramine interactions are associated with MAOIs, not SSRIs.