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A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.
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A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
- A. "I plan to sit on a park bench for a few minutes each day."
- B. "I can try participating in group therapy every week."
- C. "I will join a book club in my neighborhood."
- D. "I should avoid entering elevators and other closed spaces."
Correct Answer: A
Rationale: The correct answer is A: "I plan to sit on a park bench for a few minutes each day." This statement indicates the client's understanding of gradual exposure therapy, a common treatment for agoraphobia. Exposure to feared situations in a controlled manner helps desensitize the client to their anxiety triggers. Sitting on a park bench signifies a small step towards facing the fear of open spaces. Choices B, C, and D do not directly address the core issue of agoraphobia or the specific treatment approach. Group therapy and joining a book club may be beneficial but do not target the fear of open spaces. Avoiding elevators and closed spaces is a safety behavior that reinforces the fear and hinders recovery.
A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
- A. The sense of self among individual family members
- B. The future goals of the family
- C. The roles of family members
- D. The family's religious practices
Correct Answer: D
Rationale: The correct answer is D: The family's religious practices. When assessing sociocultural context, understanding the family's religious practices is essential as it influences beliefs, values, behaviors, and interactions within the family system. Religious practices can shape decision-making processes and coping strategies. A: The sense of self focuses on individual identity rather than the collective family system. B: Future goals pertain to the family's aspirations and plans, which are important but not directly related to sociocultural context. C: Roles of family members are significant in understanding family dynamics but do not capture the broader sociocultural influences.
A nurse is caring for an older adult client who had a cerebrovascular accident and has left-sided weakness. The client's partner tells the nurse she is worried about the next steps of treatment for her partner. Which of the following responses should the nurse make?
- A. "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable."
- B. "Your partner is too critical to consider what tomorrow will bring. Let's just concentrate on today."
- C. "Don't worry. Most clients like your partner start making progress after a few days of rest."
- D. "You will have to speak to the provider for that information. I can arrange that for you."
Correct Answer: A
Rationale: The correct answer is A because rehabilitation is an essential part of the treatment plan for an older adult client who has had a cerebrovascular accident with left-sided weakness. Sending the client to a rehabilitation facility will help them regain strength, mobility, and independence. It is important to start planning for rehabilitation early to optimize outcomes.
Choice B is incorrect because it dismisses the partner's concerns and fails to address the importance of rehabilitation. Choice C is incorrect because it gives false reassurance and oversimplifies the recovery process. Choice D is incorrect because it does not provide the necessary information and shifts the responsibility to the provider without offering support or guidance.
A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client's partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?
- A. "Do not worry about that. Your wife will be fine."
- B. "I think you should calm down a little before you see your partner."
- C. "Why do you think the crash is your fault?"
- D. "Tell me more about your feelings about what happened to your partner."
Correct Answer: D
Rationale: Encouraging the partner to express emotions helps with emotional processing and coping.
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding?
- A. Alcohol tolerance produces physical changes when I haven't recently ingested alcohol.'
- B. Alcohol tolerance causes me to have an increased effect when taking opiates.'
- C. I will develop a decreased physical response to alcohol.'
- D. Alcohol tolerance is a medical emergency and can develop as a result of withdrawal.'
Correct Answer: C
Rationale: The correct answer is C: "I will develop a decreased physical response to alcohol." This statement indicates understanding of alcohol tolerance, where the body becomes less responsive to the effects of alcohol over time, requiring larger amounts to achieve the same effect. Choice A is incorrect as alcohol tolerance actually leads to a decreased response, not physical changes when alcohol is not consumed. Choice B is incorrect as alcohol tolerance does not affect the response to opiates. Choice D is incorrect as alcohol tolerance is not a medical emergency; it is a gradual adaptation to alcohol consumption.