Nokea
A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?
- A. Encouraging decision-making
- B. Playing a game of chess with the client
- C. Giving the client choices of activities
- D. Spending time sitting with the client
Correct Answer: D
Rationale: The correct answer is D: Spending time sitting with the client. This approach is therapeutic as it promotes a sense of companionship, support, and comfort for the client. By being present and engaged in the moment, the nurse can establish trust and demonstrate empathy towards the client, which are crucial in the treatment of severe depression. This approach also provides an opportunity for the client to express their feelings and thoughts in a safe and non-judgmental environment.
Choice A, encouraging decision-making, may overwhelm the client who is dealing with severe depression and may exacerbate their feelings of helplessness. Choice B, playing a game of chess, may be too stimulating or competitive for the client in this vulnerable state. Choice C, giving the client choices of activities, may add unnecessary pressure and decision-making burden on the client. Overall, spending time sitting with the client is the most appropriate and therapeutic nursing approach in this scenario.
You may also like to solve these questions
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
- A. Difficulty relaxing
- B. Irrational fear of certain objects
- C. Rule-conscious behavior
- D. Unaware of compulsions
- E. Perfectionist behavior
Correct Answer: A, B, C, E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Difficulty relaxing is an expected finding in OCD due to persistent intrusive thoughts causing anxiety and tension.
B: Irrational fear of certain objects is common in OCD, leading to compulsive behaviors to reduce anxiety.
C: Rule-conscious behavior is a characteristic of OCD where individuals feel compelled to follow specific routines or rules.
E: Perfectionist behavior is a common trait in OCD as individuals strive for perfection to alleviate anxiety.
Incorrect Choices:
D: Individuals with OCD are usually aware of their compulsions, distinguishing them from other disorders.
F, G: No additional choices provided.
Summary:
The correct answers (A, B, C, E) align with the typical symptoms of OCD, including anxiety, compulsions, rule-following, and perfectionism. The incorrect choices (D, F, G) do not accurately reflect the expected findings in OCD.
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.
A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include?
- A. "You will give up your right to refuse antidepressant medications upon admission."
- B. "Your provider is required to notify your employer of your admission."
- C. "You will still need to give informed consent for treatments after admission."
- D. "You cannot leave the facility until your provider completes a discharge summary."
Correct Answer: C
Rationale: The correct answer is C: "You will still need to give informed consent for treatments after admission." This statement is important to include in teaching because even after being admitted to a mental health facility, the client retains the right to give informed consent for any treatments or interventions. It emphasizes the client's autonomy and involvement in decision-making regarding their care.
The other options are incorrect:
A: "You will give up your right to refuse antidepressant medications upon admission." This statement is incorrect as the client still has the right to refuse specific treatments even after admission.
B: "Your provider is required to notify your employer of your admission." This statement is incorrect as confidentiality laws protect the client's privacy and do not require notification to the employer.
D: "You cannot leave the facility until your provider completes a discharge summary." This statement is incorrect as the client has the right to leave the facility against medical advice, although there may be consequences or processes to follow.
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 home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
- A. Honk the car horn to get the client's attention.
- B. Calmly speak the client's name out of the car window.
- C. Keep driving in a path that is going away from the client's house.
- D. Stop the car in the client's driveway and call the authorities.
Correct Answer: C
Rationale: Leaving the situation and seeking help from authorities is the safest course of action.