Nokea
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?
- A. "I will assist you in getting out of bed and getting dressed."
- B. "You can remain in bed until you feel well enough to join the group."
- C. "The unit rules state that you may not remain in bed."
- D. "If you don’t participate in your care, you will not get better."
Correct Answer: A
Rationale: Rationale: Choice A is correct because it demonstrates empathy, support, and encouragement. By offering assistance in getting out of bed and getting dressed, the nurse is promoting the client's self-care and well-being. This statement acknowledges the client's feelings while also providing the necessary support to engage in daily activities.
Incorrect Choices:
B: This choice enables the client's avoidance behavior and does not promote active participation in therapy or self-care.
C: This statement is authoritarian and does not address the client's emotional state or needs, which can worsen the client's depression.
D: This statement is negative and may induce guilt or shame in the client, which is counterproductive in supporting their mental health recovery.
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A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
- A. Administer diazepam.
- B. Raise the side rails of the bed.
- C. Obtain a medical history.
- D. Start intravenous fluids.
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
- A. Provide professional counseling for staff members.
- B. Change policies for staff observation of clients who are suicidal.
- C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.
- D. Give the family an opportunity to talk about their feelings.
Correct Answer: C
Rationale: The correct answer is C: Identify cues in the client's behavior that might have warned them that he was contemplating suicide. This is the priority intervention because understanding the warning signs can help prevent future suicides by recognizing and addressing high-risk behaviors. Providing counseling (A) is important but not the immediate priority. Changing policies (B) may be necessary in the long term but does not address the current situation. Giving the family an opportunity to talk (D) is important for support but does not directly address staff intervention.
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 an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make?
- A. Promote appropriate behavior during group therapy sessions.
- B. Encourage client input in the treatment plan.
- C. Communicate with the client using concrete language.
- D. Demonstrate assertive behavior.
Correct Answer: A
Rationale: The correct answer is A: Promote appropriate behavior during group therapy sessions. For a client with histrionic personality disorder, the priority intervention is to establish boundaries and promote appropriate behavior to ensure a therapeutic environment. This is crucial in managing attention-seeking behaviors and maintaining focus on the therapeutic goals. Encouraging client input in the treatment plan (B) is important but not the priority at this stage. Communicating with concrete language (C) may be helpful but does not address the immediate need for behavior management. Demonstrating assertive behavior (D) is not the priority as it may escalate the situation.