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A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication that the client is in the denial phase of the grief process?
- A. I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!
- B. Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.
- C. The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.
- D. The doctor has been so good to me. I know he has tried everything he can. It's just my time.
Correct Answer: C
Rationale: The correct answer is C. In this response, the client is demonstrating denial by refusing to accept the doctor's prognosis of having only a few months to live. This indicates an inability to acknowledge the severity of the situation, a common characteristic of the denial phase in the grief process. The client's belief that the doctor is exaggerating shows a defense mechanism to cope with the overwhelming truth. Options A, B, and D do not exemplify denial. Option A shows anger, Option B indicates depression, and Option D reflects acceptance and resignation, which are not characteristics of denial in the grief process.
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A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?
- A. Recurrent thoughts of past trauma
- B. Invents words that have no meaning
- C. Preoccupied with folding clothes
- D. Periods of elation with unusual talkativeness
Correct Answer: B
Rationale: The correct answer is B: Invents words that have no meaning. This behavior is associated with a symptom of schizophrenia called "neologisms," where individuals create new words that are not part of any known language. This is a characteristic feature of disorganized thinking in schizophrenia. Recurrent thoughts of past trauma (choice A) are more aligned with symptoms of PTSD rather than schizophrenia. Being preoccupied with folding clothes (choice C) is more indicative of obsessive-compulsive disorder. Periods of elation with unusual talkativeness (choice D) are more likely symptoms of bipolar disorder rather than schizophrenia.
A nurse is providing teaching to a client who has an alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
- A. I am responsible for my alcoholism.
- B. I am powerless against my addiction to alcohol.
- C. I need to see a counselor who will be responsible for my recovery.
- D. I need to identify things that cause me to be an alcoholic.
Correct Answer: B
Rationale: Admitting powerlessness over alcohol aligns with AA’s first step.
Which of the following factors increases a client's risk of experiencing a crisis?
- A. Stable employment
- B. Positive coping skills
- C. History of trauma
- D. Strong social support system
Correct Answer: C
Rationale: The correct answer is C: History of trauma. A history of trauma increases a client's risk of experiencing a crisis due to unresolved emotional wounds, triggering distressing memories, and impacting their ability to cope effectively. Trauma can lead to heightened stress responses and exacerbate mental health issues, making individuals more vulnerable to crises.
Incorrect choices: A) Stable employment and D) Strong social support system are protective factors that reduce the risk of crises. B) Positive coping skills enhance resilience and help individuals manage stress effectively, decreasing crisis likelihood.
A nurse is assessing a client who is experiencing a thyroid storm. Which of the following findings should the nurse anticipate?
- A. Coma
- B. Hypothermia
- C. Tachycardia
- D. Fruity smelling breath
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. In a thyroid storm, there is an excessive release of thyroid hormones leading to severe symptoms. Tachycardia is a hallmark sign due to the increased metabolic rate and sympathetic response. Coma (A) is a severe complication but not an anticipated finding. Hypothermia (B) is incorrect as the body temperature is typically elevated. Fruity smelling breath (D) is more indicative of diabetic ketoacidosis, not thyroid storm.
What treatment is commonly used for aggressive behavior disorder?
- A. Hypnosis
- B. Cognitive-behavioral therapy (CBT)
- C. Medication
- D. Physical restraint
Correct Answer: B
Rationale: The correct answer is B: Cognitive-behavioral therapy (CBT). CBT is effective for aggressive behavior disorder as it helps individuals identify and change negative thought patterns and behaviors that contribute to aggression. It teaches coping skills and problem-solving techniques to manage anger and impulses. Hypnosis (A) is not typically used for aggressive behavior. Medication (C) may be prescribed in some cases, but it is often used in conjunction with therapy. Physical restraint (D) is a last resort and not a primary treatment for aggressive behavior.