Nokea
A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?
- A. I remember how depressed I was after my friend died.
- B. You should start participating in your usual activities.
- C. Everyone feels depressed during the grieving process.
- D. Tell me what your relationship with your partner was like.
Correct Answer: D
Rationale: This response opens a conversation about the client’s feelings and experiences, showing empathy and a willingness to understand their perspective. It helps build trust and rapport, allowing the nurse to provide appropriate support.
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A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Involved in community activities.
- C. Submissive personality.
- D. Absence of impulsive behaviors.
Correct Answer: A
Rationale: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake, and I won't let it take all of my blood. Which of the following responses should the nurse make?
- B. Your provider requires this blood specimen.
- C. You must be mistaken. Snakes cannot be in the clinic.
- D. I'm using a syringe to obtain your blood, not a snake.
- E. I don't see a snake, but that must be scary for you.
Correct Answer: D
Rationale: Acknowledging the client's hallucination and expressing empathy is the most appropriate response. By saying, 'I don't see a snake, but that must be scary for you,' the nurse acknowledges the client's fear and provides comfort without reinforcing the hallucination. This approach helps build trust and rapport, making it easier to proceed with the necessary procedure while ensuring the client's emotional wellbeing.
A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?
- A. The client goes to their room alone when they feel overwhelmed.
- B. The client displaces their feelings of self-harm until they talk to the provider.
- C. The client suppresses their feelings when they are angry.
- D. The client notifies the nurse when they want to harm themselves.
Correct Answer: D
Rationale: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.
A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?
- A. Gradual onset
- B. Impaired judgment
- C. Difficulty swallowing
- D. Slowed, flat speech
Correct Answer: B
Rationale: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.
A nurse is collecting data from a client who reports cessation of nicotine use. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Weight gain
- B. Difficulty concentrating
- C. Diarrhea
- D. Restlessness
- E. Decreased appetite
Correct Answer: A,B
Rationale: Weight gain is a common manifestation after cessation of nicotine use due to increased appetite and caloric intake. Difficulty concentrating is another common symptom experienced during nicotine withdrawal due to the loss of nicotine's stimulant effects on the brain.