A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect?
- A. Dismissal of past failures
- B. Psychomotor agitation
- C. An increase in energy
Correct Answer: B
Rationale: The correct answer is B: Psychomotor agitation. In major depressive disorder, psychomotor agitation is a common symptom characterized by restlessness, pacing, fidgeting, or hand-wringing. This is due to the increased inner tension and anxiety experienced by the individual. Dismissal of past failures (A) is not a typical finding in major depressive disorder, as individuals often dwell on negative thoughts. An increase in energy (C) is unlikely, as fatigue and low energy levels are more common in depression. The other choices are not provided, but it's important to remember that psychomotor agitation can be a key indicator in identifying major depressive disorder.
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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.
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients.” The client's statement is an example of which of the following defense mechanisms?
- A. Reaction formation
- B. Compensation
- C. Rationalization
- D. Suppression
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors, feelings, or thoughts by providing logical reasons that may not be true. In this scenario, the client is justifying their excessive drinking by blaming it on their job requirement, which is a form of rationalization.
A: Reaction formation involves expressing the opposite of how one truly feels.
B: Compensation is making up for a deficiency in one area by excelling in another.
D: Suppression is consciously pushing unwanted thoughts or feelings out of one's mind.
A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
- A. "Tell me more about how you are feeling about your son's activities!"
- B. "You might want to use tutors to home-school him."
- C. "I agree. His well-being is the most important."
- D. "You sound overprotective. Let's talk about this some more."
Correct Answer: A
Rationale: The correct response is A: "Tell me more about how you are feeling about your son's activities!" This response demonstrates active listening and empathy, allowing the mother to express her concerns and fears openly. By understanding her perspective, the nurse can provide tailored education and support to address her specific worries regarding her son's activities. This approach fosters trust and collaboration between the nurse and the mother, leading to a more effective care plan for the child.
Incorrect responses:
B: "You might want to use tutors to home-school him." - This response does not address the mother's concerns directly and suggests an extreme solution without exploring the root of her fears.
C: "I agree. His well-being is the most important." - While well-being is essential, this response does not invite further discussion or address the mother's specific worries.
D: "You sound overprotective. Let's talk about this some more." - This response may come off as judgmental and dismissive of the mother's
A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?
- A. The client will acknowledge alcohol dependence and need for treatment.
- B. The client will rebuild damaged interpersonal relationships.
- C. The client will implement alternative strategies for managing anxiety.
- D. The client's withdrawal from alcohol will be managed without complications.
Correct Answer: D
Rationale: The correct answer is D because managing alcohol withdrawal without complications is the highest priority to ensure the client's safety and well-being. Withdrawal from alcohol can lead to life-threatening complications such as seizures and delirium tremens. Addressing this goal first is crucial for stabilizing the client physically.
Choice A is important but not the highest priority as immediate physical safety takes precedence. Choices B and C are important for overall recovery but do not address the immediate risk of withdrawal complications.
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
- A. Agranulocytosis
- B. Akathisia
- C. Tardive dyskinesia
- D. Neuroleptic malignant syndrome
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). The client's symptoms of high fever, hypertension, and muscle rigidity are classic signs of NMS, a rare but life-threatening adverse effect of antipsychotic medications like haloperidol. NMS is a medical emergency that can lead to severe complications such as rhabdomyolysis, renal failure, and even death if not promptly recognized and treated. Agranulocytosis (A) is a potential side effect of some antipsychotic medications but typically presents with symptoms like fever and sore throat due to low white blood cell count. Akathisia (B) is a movement disorder characterized by restlessness and a compelling need to move, which is not consistent with the client's symptoms. Tardive dyskinesia (C) is a late-onset movement disorder associated with long-term antipsychotic use and typically presents with involuntary movements of the face and extremities, not fever