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A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
- A. Encouraging client feedback about satisfaction with the facility experience
- B. Explaining unit rules and policies regarding unacceptable behaviors
- C. Supporting the client’s wish to refuse prescribed medications
- D. Making sure the client understands expectations for participation
Correct Answer: C
Rationale: The correct answer is C: Supporting the client’s wish to refuse prescribed medications. Autonomy refers to the client's right to make their own decisions about their care. By supporting the client's wish to refuse medications, the nurse is respecting the client's autonomy and right to make decisions about their treatment. This empowers the client to have control over their own healthcare decisions.
Explanation for incorrect choices:
A: Encouraging client feedback about satisfaction with the facility experience - This choice relates to client satisfaction but does not directly address autonomy.
B: Explaining unit rules and policies regarding unacceptable behaviors - This choice focuses on rules and policies, not autonomy.
D: Making sure the client understands expectations for participation - This choice is about ensuring understanding, not necessarily autonomy.
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A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding?
- A. Alcohol tolerance produces physical changes when I haven't recently ingested alcohol.'
- B. Alcohol tolerance causes me to have an increased effect when taking opiates.'
- C. I will develop a decreased physical response to alcohol.'
- D. Alcohol tolerance is a medical emergency and can develop as a result of withdrawal.'
Correct Answer: C
Rationale: The correct answer is C: "I will develop a decreased physical response to alcohol." This statement indicates understanding of alcohol tolerance, where the body becomes less responsive to the effects of alcohol over time, requiring larger amounts to achieve the same effect. Choice A is incorrect as alcohol tolerance actually leads to a decreased response, not physical changes when alcohol is not consumed. Choice B is incorrect as alcohol tolerance does not affect the response to opiates. Choice D is incorrect as alcohol tolerance is not a medical emergency; it is a gradual adaptation to alcohol consumption.
A nurse is assessing a child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Delayed language development
- B. Spinning a toy repetitively
- C. Ritualistic behavior
- D. Consistent limit testing
Correct Answer: A, B, C
Rationale: Delayed language skills, repetitive behaviors, and a need for routines are common in autism spectrum disorder.
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients.” The client's statement is an example of which of the following defense mechanisms?
- A. Reaction formation
- B. Compensation
- C. Rationalization
- D. Suppression
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors, feelings, or thoughts by providing logical reasons that may not be true. In this scenario, the client is justifying their excessive drinking by blaming it on their job requirement, which is a form of rationalization.
A: Reaction formation involves expressing the opposite of how one truly feels.
B: Compensation is making up for a deficiency in one area by excelling in another.
D: Suppression is consciously pushing unwanted thoughts or feelings out of one's mind.
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?
- A. Premenstrual dysphoric disorder
- B. Seasonal affective disorder
- C. Major depressive disorder
- D. Persistent depressive disorder
Correct Answer: C
Rationale: The correct answer is C: Major depressive disorder. Clients with major depressive disorder are at the highest risk for suicide due to the severity of their symptoms, including feelings of hopelessness, worthlessness, and suicidal ideation. This diagnosis is associated with a higher rate of completed suicides compared to other depressive disorders. Clients with premenstrual dysphoric disorder (A) experience mood changes related to their menstrual cycle but do not typically have an increased risk of suicide. Seasonal affective disorder (B) is characterized by seasonal changes in mood and energy levels but is not typically associated with a high risk of suicide. Persistent depressive disorder (D) involves chronic depressive symptoms but does not necessarily indicate an increased risk of suicide.
A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?
- A. Decreased auditory and visual acuity
- B. Decreased display of emotions
- C. Personality traits that are opposite of original traits
- D. Forgetfulness gradually progressing to disorientation
Correct Answer: D
Rationale: Dementia typically presents with progressive forgetfulness and eventual disorientation.