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A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?
- A. "You have a great deal to live for."
- B. "It’s not unusual for depressed people to feel that way."
- C. "Why do you feel you are worthless?"
- D. "You’ve been feeling that your life has no meaning."
Correct Answer: D
Rationale: Reflecting the client’s emotions helps encourage further discussion.
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A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
- A. Seizures
- B. Illusions
- C. Tremors
- D. Polyphagia
- E. Nystagmus
Correct Answer: A, B, C
Rationale: Answer: A, B, C are correct.
Rationale:
A: Seizures can occur during alcohol withdrawal due to CNS hyperexcitability.
B: Illusions are common manifestations due to altered sensory perception.
C: Tremors are a classic sign of alcohol withdrawal due to CNS hyperactivity.
Summary:
D: Polyphagia (excessive hunger) is not a typical physical effect of alcohol withdrawal.
E: Nystagmus (involuntary eye movements) is not commonly associated with alcohol withdrawal.
A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I'm being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?
- A. "Why do you feel that you need to leave?"
- B. "You feel that you don't belong here?"
- C. "We are here to help you and give you the care that you need right now."
- D. "Try to take some deep breaths and I'm sure you'll feel better."
Correct Answer: C
Rationale: The correct response is C: "We are here to help you and give you the care that you need right now." This response acknowledges the client's feelings, reassures them of support, and validates their experience without dismissing their concerns. It promotes a therapeutic relationship and trust-building.
Choice A is incorrect as it does not address the client's immediate distress. Choice B is also incorrect as it may come across as invalidating the client's feelings. Choice D is incorrect as it suggests a quick fix without addressing the client's underlying concerns.
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Viral infection
- C. Increased energy
- D. Increased cognitive awareness
Correct Answer: B
Rationale: The correct answer is B: Viral infection. Chronic stress weakens the immune system, making the individual more susceptible to infections like viral illnesses. This is due to the prolonged release of stress hormones, which suppress immune function. Hypotension (A) is unlikely as stress typically raises blood pressure. Increased energy (C) is less likely as chronic stress often leads to fatigue. Increased cognitive awareness (D) is not a common finding with chronic stress, as it can impair cognitive function.
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
- A. Identify the client's nutritional status.
- B. Request a mental health consult.
- C. Plan a therapeutic diet for the client.
- D. Provide a structured environment for the client.
Correct Answer: A
Rationale: The correct answer is A: Identify the client's nutritional status. The priority is to assess the client's nutritional status due to the significant weight loss. This will help determine if the client is at risk of malnutrition or other health issues. B, requesting a mental health consult, is not the first priority as addressing the client's physical health is crucial before addressing mental health concerns. Planning a therapeutic diet (C) can come after assessing the nutritional status. Providing a structured environment (D) may be important but not as critical as determining the client's nutritional status first.
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Delusions
- B. Hallucinations
- C. Social withdrawal
- D. Agitation
- E. Flat affect
Correct Answer: C
Rationale: The correct answer is C: Social withdrawal. Negative symptoms in schizophrenia involve the absence or reduction of normal behaviors or functions. Social withdrawal is a common negative symptom, characterized by the client's lack of interest in social interactions. Delusions (A) and hallucinations (B) are positive symptoms, involving the presence of abnormal behaviors or perceptions. Agitation (D) is a symptom of increased motor activity, not a negative symptom. Flat affect (E) refers to a lack of emotional expression, which is also a negative symptom. In summary, social withdrawal aligns with the definition of negative symptoms in schizophrenia, making it the correct answer.