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A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.
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A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?
- A. Sit with the client and offer simple, direct information.
- B. Have the client attend group therapy immediately.
- C. Explain the unit policies to the client and answer any questions he might have.
- D. Take the client on a tour of the unit and introduce him to all the staff members on duty.
Correct Answer: A
Rationale: Clients with severe depression may have difficulty processing large amounts of information, so simple, direct communication is best.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
- A. "You are being unreasonable, and I will not call your doctor at this hour."
- B. "I can't call a doctor in the middle of the night unless it's an emergency."
- C. "Go back to your room, and I'll try to get in touch with your doctor."
- D. "You must be very upset about something."
Correct Answer: D
Rationale: The correct answer is D: "You must be very upset about something." This response is appropriate because it acknowledges the client's emotions and demonstrates empathy. It shows the nurse's understanding of the client's distress, which is crucial in building a therapeutic relationship. By validating the client's feelings, the nurse can de-escalate the situation and gather more information to address the client's needs effectively.
Choice A is incorrect because it dismisses the client's request and can escalate the situation. Choice B is incorrect as it fails to acknowledge the client's emotions and lacks empathy. Choice C is incorrect as it does not address the client's emotional state and may lead to further agitation.
A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?
- A. Nystagmus
- B. Dilated pupils
- C. Hypersomnia
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Dilated pupils. Cocaine intoxication typically presents with dilated pupils due to the drug's stimulant effects on the sympathetic nervous system. This causes pupil dilation by increasing the release of norepinephrine. Nystagmus (choice A) is not a common finding in cocaine intoxication. Hypersomnia (choice C) is unlikely as cocaine is a stimulant that often leads to decreased need for sleep. Depression (choice D) is not a typical symptom of cocaine intoxication. In summary, dilated pupils are a key indicator of cocaine intoxication, while nystagmus, hypersomnia, and depression are not characteristic findings.
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
- A. Denial
- B. Displacement
- C. Projection
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of "I'm fine" despite having traumatic injuries indicate a defense mechanism of denial, where the client is refusing to acknowledge the severity of their situation. Denial helps the individual cope with overwhelming emotions or stress by avoiding the reality of the situation. Displacement involves redirecting emotions to a less threatening target, projection involves attributing one's thoughts or feelings to others, and undoing involves engaging in behaviors to counteract negative thoughts or actions. In this scenario, denial is the most appropriate reaction based on the client's behavior.