Nokea
A nurse is caring for a client who has an eating disorder. The nurse is practicing which of the following ethical concepts when the client refuses to drink a between-meal protein and calorie supplement?
- A. Autonomy
- B. Beneficence
- C. Veracity
- D. Fidelity
Correct Answer: A
Rationale: Respecting the client’s decision to refuse food aligns with the ethical principle of autonomy.
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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 on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
- A. Suggest that the client rest in bed.
- B. Remain with the client for a while.
- C. Medicate the client with a sedative.
- D. Have the client join a therapy group.
Correct Answer: B
Rationale: The correct answer is B: Remain with the client for a while. This is the most therapeutic action as it provides immediate support and reassurance to the client experiencing panic-level anxiety. Remaining with the client allows the nurse to offer a calming presence, demonstrate empathy, and help the client feel safe and supported. It also helps to establish a therapeutic relationship and can assist in de-escalating the client's anxiety.
A: Suggesting the client rest in bed may not address the client's immediate emotional needs and could be perceived as dismissive.
C: Medicating the client with a sedative should only be done after a thorough assessment by a healthcare provider and is not the initial therapeutic action.
D: Having the client join a therapy group may be overwhelming for someone experiencing panic-level anxiety and may not be the most appropriate intervention at this time.
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?
- A. Prior physical health followed by the need for two surgeries within the last three months.
- B. Obsession over a fictitious defect in physical appearance.
- C. Sudden unexplained loss of peripheral sensation.
- D. Constant worry about the undiagnosed presence of an illness.
Correct Answer: D
Rationale: The correct answer is D because individuals with illness anxiety disorder experience persistent and excessive worry about having a serious medical condition despite reassurance from healthcare providers. This constant preoccupation with the possibility of being sick is a key characteristic of the disorder. Option A is incorrect as surgeries do not directly relate to illness anxiety disorder. Option B describes body dysmorphic disorder, not illness anxiety disorder. Option C does not align with the typical presentation of illness anxiety disorder.
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.
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?
- A. "It will help you feel better if you talk about it."
- B. "I'll come back when you feel like talking."
- C. "I'll stay with you a few minutes."
- D. "Coming with me to the day room will take your mind off your troubles."
Correct Answer: C
Rationale: Staying with the client provides support without pressuring them to talk.