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A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?
- A. Determine whether the client's goals are met.
- B. Collect data about the client's current health status.
- C. Provide the client with information on problem-solving.
- D. Establish a regular meeting time with the client.
Correct Answer: C
Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.
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A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend implementing to assist the client with performing ADLs?
- A. Provide a stimulating environment for the client.
- B. Offer the client several choices for daily activities and meals.
- C. Give the client clothing with elastic or fastening tape.
- D. Keep the bedroom dark while the client is sleeping.
Correct Answer: C
Rationale: Providing clothing with elastic or fastening tape simplifies the process of dressing and undressing, making it easier for the client to maintain independence in ADLs. This type of clothing can reduce frustration and promote a sense of autonomy, which is crucial for clients with Alzheimer's disease.
A nurse is discussing the care of a client who has alcohol use disorder with another nurse. Which of the following statements should the nurse identify as an indication of countertransference?
- A. The client is just like my parent, who never could quit drinking.
- B. The client needs to accept responsibility for their drinking.
- C. The client asked me to go on a date.
- D. The client shares their feelings openly during group therapy.
Correct Answer: A
Rationale: This statement is an indication of countertransference because the nurse is projecting personal feelings and experiences onto the client. By comparing the client to their parent who struggled with drinking, the nurse may unconsciously treat the client differently based on unresolved emotions or past experiences. Countertransference can interfere with the nurse's ability to provide objective and compassionate care.
A nurse is reinforcing teaching with a client about naltrexone. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will not experience alcohol withdrawal if I take this medication.
- B. The medication will allow me to gradually decrease my alcohol intake.
- C. If I drink alcohol with this medication, I will experience ringing in my ears.
- D. Taking this medication will reduce my cravings for alcohol.
Correct Answer: D
Rationale: This statement accurately reflects one of the primary effects of naltrexone. The medication helps reduce cravings for alcohol, making it easier for individuals to maintain abstinence and avoid relapse. By understanding this aspect of naltrexone, the client demonstrates a clear understanding of its purpose and use in alcohol dependence treatment.
A nurse is collecting data for a health history from a client who has bulimia nervosa. Which of the following laboratory findings should the nurse expect?
- A. Hypokalemia
- B. Leukopenia
- C. Decreased serum amylase
- D. Hematuria
Correct Answer: A
Rationale: Hypokalemia, or low potassium levels in the blood, is a common finding in individuals with bulimia nervosa, especially those who engage in frequent vomiting or use laxatives. Purging behaviors can lead to significant electrolyte imbalances, including potassium depletion, which can cause muscle weakness, cramps, and cardiac arrhythmias.
A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?
- A. Unable to make simple decisions
- B. Enjoys spending time alone
- C. Exhibits extreme perfectionism
- D. Displays confrontational behavior
Correct Answer: A
Rationale: Individuals with dependent personality disorder often struggle with making simple decisions without excessive advice and reassurance from others. They have a strong need for others to take responsibility for major areas of their lives and can feel helpless when alone. This indecisiveness is a hallmark of the disorder and stems from their lack of self-confidence and reliance on others for guidance and support.