Nokea
A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion?
- A. "I like to cut my food into small pieces."
- B. "I really need to get into shape."
- C. "If I eat one piece of candy, I may as well eat ten."
- D. "I can't afford to gain weight."
Correct Answer: C
Rationale: Cognitive distortions involve irrational thought patterns, such as all-or-nothing thinking.
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A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?
- A. Call for assistance to place the client in restraints.
- B. Escort the client to an unlocked seclusion room.
- C. Offer the client a PRN antianxiety medication.
- D. Speak to the client calmly, giving simple directions.
Correct Answer: D
Rationale: The correct answer is D: Speak to the client calmly, giving simple directions. This is the first action the nurse should take because it focuses on de-escalating the situation and ensuring the safety of the client and others. By speaking calmly and giving simple directions, the nurse can help the client regain control and potentially prevent further escalation. Calling for assistance to place the client in restraints (A) should only be used as a last resort for safety reasons. Escorting the client to an unlocked seclusion room (B) may escalate the situation further. Offering a PRN antianxiety medication (C) should only be considered after assessing the client and obtaining an order from a healthcare provider.
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 is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how alcohol use affects the client's psychosocial behaviors?
- A. "Has alcohol use affected your performance at work?"
- B. "Have you received prior treatment for substance use disorder?"
- C. "Do you receive treatment for any mental health disorders?"
- D. "At what age did you begin drinking alcohol?"
Correct Answer: A
Rationale: The correct answer is A. By asking if alcohol use has affected the client's performance at work, the nurse can assess the impact of alcohol on the client's psychosocial behaviors, such as work productivity and relationships with colleagues. This question directly addresses the behavioral consequences of alcohol use.
Explanation for incorrect choices:
B: Asking about prior treatment for substance use disorder focuses on the past rather than the current impact on psychosocial behaviors.
C: Inquiring about treatment for mental health disorders is relevant but does not specifically address the psychosocial effects of alcohol use.
D: Asking at what age the client began drinking alcohol provides historical information but does not assess current psychosocial behaviors.
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.
Which medication is commonly prescribed to treat obsessive-compulsive disorder (OCD)?
- A. Paroxetine
- B. Lithium
- C. Donepezil
- D. Valproate
- E. Carbamazepine
Correct Answer: A
Rationale: The correct answer is A: Paroxetine. Paroxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for OCD due to its effectiveness in increasing serotonin levels in the brain, which helps reduce obsessive thoughts and compulsive behaviors. Lithium, Donepezil, Valproate, and Carbamazepine are not typically used to treat OCD as they are more commonly indicated for conditions such as mood disorders, Alzheimer's disease, epilepsy, and bipolar disorder, respectively. Therefore, Paroxetine is the most appropriate choice for treating OCD based on its mechanism of action and proven efficacy.