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A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
- A. The sense of self among individual family members
- B. The future goals of the family
- C. The roles of family members
- D. The family's religious practices
Correct Answer: D
Rationale: The correct answer is D: The family's religious practices. When assessing sociocultural context, understanding the family's religious practices is essential as it influences beliefs, values, behaviors, and interactions within the family system. Religious practices can shape decision-making processes and coping strategies. A: The sense of self focuses on individual identity rather than the collective family system. B: Future goals pertain to the family's aspirations and plans, which are important but not directly related to sociocultural context. C: Roles of family members are significant in understanding family dynamics but do not capture the broader sociocultural influences.
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A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?
- A. "I will have your provider discuss the adverse effects with you before the treatment begins."
- B. "Someone from the American Cancer Society will be here soon to answer your questions."
- C. "What is it about the adverse effects that concern you?"
- D. "I agree. Sometimes the adverse effects can be worse than the disease."
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should respond with "What is it about the adverse effects that concern you?" This response shows empathy, encourages open communication, and allows the nurse to address the client's specific fears or concerns. It also promotes a patient-centered approach to care, enhancing trust and rapport between the nurse and the client. This response demonstrates active listening and provides an opportunity for individualized education and support.
Incorrect Answers:
A: This response defers the responsibility to the provider and does not address the client's concerns directly.
B: This response does not address the client's specific concerns and may not provide the necessary support.
D: This response dismisses the client's concerns and does not address the root of her worries, potentially increasing anxiety.
E, F, G: No information provided.
A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Expressive affect
- B. Associative looseness
- C. Echolalia
- D. Ambivalence
Correct Answer: C
Rationale: Echolalia, or repeating words/phrases, is a common communication pattern in autism spectrum disorder.
A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission from the nurse before performing activities of daily living. This behavior indicates which of the following findings?
- A. The client is ready for discharge.
- B. The client is able to function independently.
- C. The client may be having a recurrence of delirium tremens.
- D. The client is exhibiting dependency.
Correct Answer: D
Rationale: The correct answer is D: The client is exhibiting dependency. This behavior indicates that the client is relying on the nurse for permission before performing activities of daily living, suggesting a level of dependency. This is common in clients with delirium tremens as they may have cognitive impairment and need guidance for decision-making.
A: The client seeking permission does not necessarily indicate readiness for discharge.
B: The client seeking permission does not necessarily indicate ability to function independently.
C: There is no indication of a recurrence of delirium tremens based on seeking permission.
Summary: The correct answer, D, is supported by the client's behavior of seeking permission, indicating dependency. Other choices are incorrect as they do not align with the behavior exhibited by the client in this scenario.
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?
- A. "I will assist you in getting out of bed and getting dressed."
- B. "You can remain in bed until you feel well enough to join the group."
- C. "The unit rules state that you may not remain in bed."
- D. "If you don’t participate in your care, you will not get better."
Correct Answer: A
Rationale: Rationale: Choice A is correct because it demonstrates empathy, support, and encouragement. By offering assistance in getting out of bed and getting dressed, the nurse is promoting the client's self-care and well-being. This statement acknowledges the client's feelings while also providing the necessary support to engage in daily activities.
Incorrect Choices:
B: This choice enables the client's avoidance behavior and does not promote active participation in therapy or self-care.
C: This statement is authoritarian and does not address the client's emotional state or needs, which can worsen the client's depression.
D: This statement is negative and may induce guilt or shame in the client, which is counterproductive in supporting their mental health recovery.
A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.