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A nurse is assessing a client who has post-traumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
- A. Sleeping 12 hours or more each day
- B. Increasing sense of attachment to others
- C. Constricted willingness to talk about the event
- D. Increasing feelings of anger
Correct Answer: C
Rationale: Avoidance of discussing the traumatic event is a key symptom of PTSD.
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A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.
Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
- A. Isolate the client for a period of time.
- B. Confront the client about the senseless nature of the repetitive behaviors.
- C. Plan the client's schedule to allow time for rituals.
- D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Correct Answer: C
Rationale: The correct answer is C: Plan the client's schedule to allow time for rituals. This is the most appropriate action as it acknowledges the client's need for engaging in compulsive behaviors while also structuring the time effectively. Isolating the client (Choice A) would be counterproductive, as social isolation can exacerbate OCD symptoms. Confronting the client (Choice B) may lead to increased anxiety and resistance. Setting strict limits (Choice D) can cause distress and potential non-compliance. The key is to support the client by incorporating their rituals into the schedule while working towards gradually reducing them in a therapeutic manner.
A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?
- A. "Why would you want to put your partner's health at further risk?"
- B. "You will need to discuss your concerns about your partner's diet with the provider."
- C. "Everyone likes food from home, but it can delay your partner's recovery."
- D. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
Correct Answer: D
Rationale: The correct answer is D: "Let's try to find ways to incorporate your partner's favorite food into her diet plan." This response acknowledges the partner's desire to bring food from home while also emphasizing the importance of adhering to the client's dietary plan for recovery. By suggesting a compromise to incorporate the favorite food within the diet plan, the nurse is promoting collaboration and patient-centered care. It shows understanding and empathy towards the partner's concerns while prioritizing the client's health and recovery.
Choice A is incorrect as it may come off as judgmental and dismissive. Choice B is not the most appropriate response as it doesn't address the partner's request directly. Choice C is incorrect as it may sound like a blanket statement and could potentially create tension between the nurse and the partner.
A charge nurse is preparing an educational session about addictive disorders for nursing staff. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.)
- A. Low self-esteem
- B. Family history of addiction
- C. Personality disorders
- D. Asian ethnicity
Correct Answer: A, B, C
Rationale: Low self-esteem, family history, and personality disorders are risk factors for addiction. Ethnicity is not a primary factor.