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A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
- A. Helping the client identify positive personality traits
- B. Providing for adequate hydration and rest
- C. Confronting the use of denial and other defense mechanisms
- D. Educating the client about the consequences of alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing for adequate hydration and rest. The priority in caring for a client with alcohol use disorder is addressing physical needs like hydration and rest to manage withdrawal symptoms and prevent complications. Hydration helps prevent dehydration and electrolyte imbalances, while rest supports the body's healing process. Choices A, C, and D focus on psychological aspects, which are important but secondary to addressing immediate physical needs. Helping the client identify positive traits can come later in therapy, confronting denial and defense mechanisms can be addressed once the client is stabilized, and educating about consequences is important but not as urgent as ensuring hydration and rest.
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A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I'm being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?
- A. "Why do you feel that you need to leave?"
- B. "You feel that you don't belong here?"
- C. "We are here to help you and give you the care that you need right now."
- D. "Try to take some deep breaths and I'm sure you'll feel better."
Correct Answer: C
Rationale: The correct response is C: "We are here to help you and give you the care that you need right now." This response acknowledges the client's feelings, reassures them of support, and validates their experience without dismissing their concerns. It promotes a therapeutic relationship and trust-building.
Choice A is incorrect as it does not address the client's immediate distress. Choice B is also incorrect as it may come across as invalidating the client's feelings. Choice D is incorrect as it suggests a quick fix without addressing the client's underlying concerns.
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
- A. Suggest that the client rest in bed.
- B. Remain with the client for a while.
- C. Medicate the client with a sedative.
- D. Have the client join a therapy group.
Correct Answer: B
Rationale: The correct answer is B: Remain with the client for a while. This is the most therapeutic action as it provides immediate support and reassurance to the client experiencing panic-level anxiety. Remaining with the client allows the nurse to offer a calming presence, demonstrate empathy, and help the client feel safe and supported. It also helps to establish a therapeutic relationship and can assist in de-escalating the client's anxiety.
A: Suggesting the client rest in bed may not address the client's immediate emotional needs and could be perceived as dismissive.
C: Medicating the client with a sedative should only be done after a thorough assessment by a healthcare provider and is not the initial therapeutic action.
D: Having the client join a therapy group may be overwhelming for someone experiencing panic-level anxiety and may not be the most appropriate intervention at this time.
A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
- A. "Tell me more about how you are feeling about your son's activities!"
- B. "You might want to use tutors to home-school him."
- C. "I agree. His well-being is the most important."
- D. "You sound overprotective. Let's talk about this some more."
Correct Answer: A
Rationale: The correct response is A: "Tell me more about how you are feeling about your son's activities!" This response demonstrates active listening and empathy, allowing the mother to express her concerns and fears openly. By understanding her perspective, the nurse can provide tailored education and support to address her specific worries regarding her son's activities. This approach fosters trust and collaboration between the nurse and the mother, leading to a more effective care plan for the child.
Incorrect responses:
B: "You might want to use tutors to home-school him." - This response does not address the mother's concerns directly and suggests an extreme solution without exploring the root of her fears.
C: "I agree. His well-being is the most important." - While well-being is essential, this response does not invite further discussion or address the mother's specific worries.
D: "You sound overprotective. Let's talk about this some more." - This response may come off as judgmental and dismissive of the mother's
A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior as which of the following defense mechanisms?
- A. Repression
- B. Splitting
- C. Sublimation
- D. Undoing
Correct Answer: B
Rationale: Splitting is characterized by viewing things as all good or all bad, commonly seen in personality disorders.
A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
- A. Seizures
- B. Illusions
- C. Tremors
- D. Polyphagia
- E. Nystagmus
Correct Answer: A, B, C
Rationale: Answer: A, B, C are correct.
Rationale:
A: Seizures can occur during alcohol withdrawal due to CNS hyperexcitability.
B: Illusions are common manifestations due to altered sensory perception.
C: Tremors are a classic sign of alcohol withdrawal due to CNS hyperactivity.
Summary:
D: Polyphagia (excessive hunger) is not a typical physical effect of alcohol withdrawal.
E: Nystagmus (involuntary eye movements) is not commonly associated with alcohol withdrawal.