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A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?
- A. How does this situation affect your life?
- B. Do you see your current situation affecting your future?
- C. Can you describe how you are currently feeling?
- D. How have you dealt with similar situations in the past?
Correct Answer: D
Rationale: The correct answer is D: How have you dealt with similar situations in the past? This question assesses the client's personal coping skills by exploring their past strategies for managing challenging situations. By understanding their previous coping mechanisms, the nurse can identify effective approaches to support the client in managing their current depression.
A: How does this situation affect your life? - This question focuses on the impact of the current situation but does not directly assess the client's coping skills.
B: Do you see your current situation affecting your future? - This question explores the client's perspective on the influence of the situation on their future, but it does not specifically address coping skills.
C: Can you describe how you are currently feeling? - This question evaluates the client's emotional state but does not directly assess coping skills.
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A nurse is developing a plan of care for a client who has post-traumatic stress disorder. Which of the following interventions should the nurse include?
- A. Encourage the client to suppress traumatic memories
- B. Discourage the client from discussing the trauma
- C. Encourage the client to use relaxation techniques
- D. Limit the client’s participation in activities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use relaxation techniques. This is important in managing symptoms of PTSD by helping the client to reduce anxiety and stress levels. Relaxation techniques, such as deep breathing and mindfulness, can help the client cope with distressing thoughts and emotions. Encouraging the client to use these techniques promotes self-soothing and emotional regulation.
Choice A is incorrect because suppressing traumatic memories can worsen symptoms and lead to increased distress. Choice B is incorrect as discussing the trauma in a safe and supportive environment is a key component of PTSD therapy. Choice D is incorrect as limiting activities can hinder the client's recovery process.
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
- A. Weigh the client twice per day
- B. Prepare the client for electroconvulsive therapy
- C. Set a weight gain goal of 2.2kg (5lbs) per week
- D. Encourage the client to participate in family therapy
Correct Answer: C
Rationale: The correct answer is C: Set a weight gain goal of 2.2kg (5lbs) per week. This intervention is appropriate for a client with anorexia nervosa to promote healthy weight restoration. Rapid weight gain can be harmful, so setting a realistic goal helps prevent complications. Weighing the client twice per day (A) can exacerbate anxiety and reinforce obsessive behaviors. Electroconvulsive therapy (B) is not indicated for anorexia nervosa. Encouraging family therapy (D) may be beneficial, but the priority is weight restoration.
A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam?
- A. Bradycardia
- B. Stupor
- C. Afebrile
- D. Hypertension
Correct Answer: D
Rationale: The correct answer is D: Hypertension. Lorazepam is a benzodiazepine commonly used to manage alcohol withdrawal symptoms, including hypertension. Alcohol withdrawal often leads to increased sympathetic nervous system activity, causing elevated blood pressure. Lorazepam helps to reduce this symptom by promoting relaxation and reducing anxiety. Bradycardia (A), stupor (B), and afebrile (C) are not indications for lorazepam administration in alcohol withdrawal. Bradycardia and stupor may require further evaluation for potential complications, while afebrile state does not directly warrant lorazepam use.
A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take?
- A. Withhold the next dose of lithium
- B. Repeat the lithium level test
- C. Administer the next dose of lithium
- D. Recommend a low sodium diet
Correct Answer: C
Rationale: The correct answer is C: Administer the next dose of lithium. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L), so the nurse should continue the medication as prescribed. Withholding the dose (choice A) can lead to subtherapeutic levels and ineffective treatment. Repeating the test (choice B) is unnecessary as the current level is within the therapeutic range. Recommending a low sodium diet (choice D) is not directly related to lithium therapy.
A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Readily initiates conversation
- B. Enjoys imaginative play
- C. Strong relationship with sibling and peers
- D. Attachment to objects that spin
Correct Answer: D
Rationale: The correct answer is D: Attachment to objects that spin. Children with autism spectrum disorder often exhibit repetitive behaviors, such as spinning objects, as a way to self-soothe or seek sensory stimulation. This behavior can serve as a coping mechanism and provide a sense of control for the child. Other choices are incorrect because children with autism spectrum disorder may have challenges in initiating conversations (A), engaging in imaginative play (B), or forming strong relationships with siblings and peers (C). By understanding the characteristics of autism spectrum disorder, the nurse can better tailor care and interventions to support the child's unique needs.