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A nurse is caring for a client who has obsessive-compulsive disorder and engages in repeated handwashing. Which of the following actions should the nurse take?
- A. Encourage the client to stop washing hands
- B. Allow the client additional time to complete rituals
- C. Set strict time limits on compulsions
- D. Ignore the client’s compulsive behavior
Correct Answer: B
Rationale: The correct answer is B: Allow the client additional time to complete rituals. This approach is known as a harm reduction strategy in managing obsessive-compulsive disorder. By allowing the client additional time to complete rituals, the nurse can help reduce the client's anxiety and provide a sense of control. Encouraging the client to stop washing hands (A) may increase anxiety and worsen symptoms. Setting strict time limits on compulsions (C) can also increase anxiety and lead to distress. Ignoring the client's compulsive behavior (D) can be harmful as it may reinforce the behavior. It is important for the nurse to be supportive and understanding of the client's struggles while working towards more effective coping strategies.
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A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive behavioral family therapy in response to which of the following client statements?
- A. I want to learn how to change the way I react to problems within my family
- B. I want to understand why my past experiences are affecting my family relationships
- C. I want to improve my family’s understanding of each other’s boundaries
- D. I want each of my family members to be more aware of each other’s feelings
Correct Answer: A
Rationale: The correct answer is A because cognitive behavioral family therapy focuses on changing negative thought patterns and behaviors. By wanting to change the way they react to family problems, the client is demonstrating a readiness to engage in cognitive restructuring and behavioral change. Choice B is incorrect as it pertains more to individual therapy exploring past experiences. Choice C is incorrect as it focuses on improving understanding of boundaries, which is not the primary goal of cognitive behavioral family therapy. Choice D is incorrect because it emphasizes awareness of feelings rather than addressing reactive behaviors.
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
- A. Rationalization
- B. Denial
- C. Compensation
- D. Displacement
Correct Answer: C
Rationale: The client is demonstrating the defense mechanism of Compensation. Compensation involves covering up weaknesses by emphasizing strengths in other areas. In this scenario, the client is compensating for feeling inadequate or unappreciated by becoming angry and defensive when his actions are questioned. This behavior serves to divert attention away from his perceived shortcomings and protect his self-esteem.
Rationalization (A) involves creating logical explanations to justify behaviors or feelings. Denial (B) is refusing to acknowledge unpleasant realities. Displacement (D) is redirecting emotions from the real target to a substitute target. In this case, these defense mechanisms are not as applicable as Compensation, which directly relates to the client's behavior of overcompensating for his perceived lack of attention.
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
- A. I don’t know how I could cope if I didn’t have my family’s support
- B. It’ll be a long time before I’m happy again
- C. I don’t feel anything but numbness anymore
- D. I feel like I’m angry at the whole world right now
Correct Answer: C
Rationale: The correct answer is C: "I don’t feel anything but numbness anymore." This statement indicates a significant emotional numbness, which is a common symptom of clinical depression. It suggests a lack of normal emotional responses, which can be concerning.
Choice A does not specifically indicate clinical depression but rather expresses a need for support. Choice B reflects a natural response to grief and does not necessarily indicate depression. Choice D suggests anger, which can also be a normal part of the grieving process.
In summary, Choice C is the correct answer as it directly points to a key symptom of clinical depression, while the other choices reflect common emotional responses to grief that may not necessarily indicate depression.
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
- A. Place the client in a group therapy session
- B. Rotate staff members who work with the client
- C. Encourage the client to participate in physical activities
- D. Distract the client with increased environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to participate in physical activities. Physical activities can help to channel the excess energy and agitation associated with manic episodes in bipolar disorder. Exercise can help reduce stress, improve mood, and promote better sleep patterns. Group therapy (A) may not be appropriate during a manic episode as the client may have difficulty focusing and could disrupt the session. Rotating staff members (B) could lead to inconsistency in care and may worsen the client's symptoms. Distracting the client with increased environmental stimuli (D) could exacerbate agitation and overstimulation. It is important to provide a structured and safe outlet for the client's energy, hence physical activities are the most appropriate intervention in this scenario.
A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first?
- A. Request that the parent leaves the room while you interview the child
- B. Report suspected abuse to child protective services
- C. Ask the child how the injury occurred
- D. Determine the immediate safety needs of the child
Correct Answer: B
Rationale: Correct Answer: B. Report suspected abuse to child protective services.
Rationale: Reporting suspected abuse to child protective services is the first step to ensure the safety and well-being of the child. In cases of conflicting stories from the parent and the child, it is crucial to prioritize the child's safety. Child protective services can investigate further to determine the true cause of the injury and provide necessary support and protection for the child.
Summary of other choices:
A: Requesting the parent to leave the room may be necessary for further assessment, but ensuring the child's safety is the priority.
C: Asking the child how the injury occurred is important but should come after ensuring the child's immediate safety.
D: Determining the immediate safety needs of the child is crucial, but reporting suspected abuse takes precedence to address potential harm.