Nokea
A nurse in an acute care facility is assisting with the admission of an older adult client who has late stage Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his partner. Which of the following actions should the nurse take first?
- A. Suggest that the client's partner see a counselor to help him cope with his exhaustion.
- B. Encourage the client's partner to call a family meeting to ask for help.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Recommend that the client's partner place the client in a long-term care facility.
Correct Answer: C
Rationale: Counseling helps later, not first. Family meetings follow understanding needs. Asking about difficulties assesses the situation, guiding support. Recommending placement is premature without discussion.
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A young adult moves to a new town and is unable to establish relationships because of geographical distance to other towns and a sparsely populated community. This young adult is at greatest risk for which of the following?
- A. Mental illness
- B. Social isolation
- C. Substance abuse
- D. Depression
Correct Answer: B
Rationale: Mental illness is broad and less immediate. Geographical and sparse population factors directly lead to social isolation, the primary risk here. Substance abuse or depression could follow, but isolation is the most direct consequence of the situation.
A hospitalized client sees snakes on the walls of the hospital room and becomes anxious. This is an example of which of the following?
- A. Hallucinations
- B. Delirium
- C. Delusion
- D. Psychosis
Correct Answer: A
Rationale: Hallucinations involve perceiving things that aren’t present, like seeing snakes, fitting the client’s experience. Delirium is a broader state of confusion that may include hallucinations but isn’t specific to this symptom alone. Delusions are false beliefs, not perceptions. Psychosis is a general term that can include hallucinations but isn’t as precise as the specific symptom described.
A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take?
- A. Reinforce how to use assertive communication techniques.
- B. Schedule the client's daily self-care activities.
- C. Discourage the client from expressing anger.
- D. Set short-term and long-term goals for the client.
Correct Answer: D
Rationale: Assertiveness is secondary to overall planning. Scheduling self-care helps but isn’t comprehensive. Suppressing anger hinders emotional health. Goal setting provides direction and motivation, key to depression management.
In developing a nursing care plan for an adult with a mental health disorder, the nurse knows the goals that are set must be:
- A. Important to the client
- B. Evaluated on a weekly basis
- C. Achievable by client discharge
- D. Approved by the physician
Correct Answer: A
Rationale: Client-important goals boost engagement. Weekly evaluation is useful but not mandatory. Discharge-tied goals may not fit long-term needs. Physician approval is secondary to client-centered planning.
A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?
- A. Incoherent speech
- B. Irritability
- C. Insomnia
- D. Chest pain
Correct Answer: B
Rationale: Incoherent speech indicates severe anxiety. Irritability is a mild anxiety sign, with maintained function. Insomnia suggests chronic anxiety. Chest pain aligns with severe anxiety or panic.