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A nurse is caring for a client who is refusing to attend group therapy. The client states,I don't know why you think I need therapy. I am fine without it. Which of the following responses by the nurse indicates a therapeutic response?
- A. I understand that you feel like you don't need it; however, the provider thinks it will help.
- B. You don't feel like group therapy is for you. Tell me more about what you know about group therapy.
- C. I am not saying that you need therapy, but I am sure it will help you.
- D. You don't have to be afraid to go. Our therapists are very understanding.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B demonstrates therapeutic communication by showing empathy and understanding towards the client's feelings and inviting further discussion. By encouraging the client to express their thoughts on group therapy, the nurse opens up a dialogue to explore the client's beliefs and concerns, fostering trust and rapport. This approach respects the client's autonomy and promotes client-centered care.
Summary of Incorrect Choices:
A: This response dismisses the client's feelings and focuses on the provider's opinion, potentially alienating the client and not addressing their concerns.
C: This response minimizes the client's feelings and imposes the nurse's beliefs, which may lead to resistance and hinder the therapeutic relationship.
D: This response invalidates the client's emotions by assuming fear as the underlying issue and may create defensiveness rather than addressing the client's actual concerns.
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A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
- A. If a dose is missed, do not double the next dose of medication.
- B. This medication may cause dizziness upon standing.
- C. Use a dependable form of contraception while taking this medication.
- D. Do not drink alcohol while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: This medication may cause dizziness upon standing. Alprazolam is a benzodiazepine that can cause dizziness as a side effect, especially when standing up quickly. This information is important for the client to prevent falls or accidents.
A: Missing a dose should not be addressed by doubling the next dose as it can lead to overdose or adverse effects.
C: Although contraceptives might be important to discuss, it is not specifically related to the medication itself.
D: Alcohol should be avoided while taking alprazolam due to the increased risk of side effects and potential interactions, but it is not the most crucial information for the client's safety.
A nurse is educating a 28-year-old female client about the impacts of hypothyroidism on overall health. Which of the following statements would the nurse include in the teaching?
- A. If you become pregnant, low thyroid hormone levels can affect your developing fetus.
- B. Hypothyroidism can cause autoimmune disorders over time.
- C. Low thyroid hormone levels will cause your metabolism to speed up and heart rate to increase.
- D. Low blood pressure is usually associated with hypothyroidism.
Correct Answer: A
Rationale: Rationale: The correct answer is A because hypothyroidism, characterized by low thyroid hormone levels, can lead to complications during pregnancy, affecting fetal development. This is due to the essential role of thyroid hormones in fetal brain and nervous system development.
Summary of Incorrect Choices:
B: Hypothyroidism is linked to autoimmune disorders, not a consequence of it.
C: Hypothyroidism actually slows down metabolism and heart rate due to decreased thyroid hormone levels.
D: Low blood pressure is more commonly associated with hyperthyroidism, where the thyroid is overactive.
A nurse is caring for a client who is newly diagnosed with hyperthyroidism and reports dry eyes and sensitivity to light. The nurse notes that the client's eyes have a bulging appearance. Which of the following should the nurse include in the client's plan of care?
- A. Exposure to sunlight will help to strengthen your eyes.
- B. These are unusual symptoms. I will ask the provider for an ophthalmology referral.
- C. Eye drops and dim lighting can improve your symptoms.
- D. Surgery will be necessary to correct the damage to your eyes.
Correct Answer: C
Rationale: The correct answer is C: Eye drops and dim lighting can improve your symptoms. In hyperthyroidism, the bulging appearance of the eyes, known as exophthalmos, can lead to dry eyes and sensitivity to light. Eye drops can help alleviate dryness, and dim lighting can reduce discomfort from light sensitivity. This intervention addresses the client's specific symptoms and promotes comfort.
Choice A is incorrect because sunlight exposure can exacerbate light sensitivity in clients with hyperthyroidism. Choice B is incorrect as it does not provide a direct intervention for the client's symptoms and delays addressing the discomfort. Choice D is incorrect because surgery is not typically the first-line treatment for eye symptoms in hyperthyroidism; conservative measures are usually tried first.
A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states,I'm frightened. Do you hear that? The voices are telling me to do terrible things. Which of the following responses by the nurse is appropriate?
- A. What are the voices telling you to do?
- B. You need to tell the voices to leave you alone.
- C. You need to understand that there are no voices.
- D. Why do you think you are hearing the voices?
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. **Acknowledge the client's experience**: By asking "What are the voices telling you to do?" the nurse validates the client's experience and shows empathy.
2. **Encourages communication**: This response opens up a dialogue and allows the nurse to gather more information for assessment and understanding.
3. **Avoids dismissing or denying the experience**: Options B and C dismiss or deny the existence of the voices, which can make the client feel unheard or misunderstood.
4. **Promotes therapeutic communication**: Asking about the content of the voices helps the nurse assess the client's level of distress and potential risk.
5. **Supports building trust**: By demonstrating active listening and showing interest in the client's experience, the nurse can build a trusting therapeutic relationship.
Summary:
- Option A is correct as it acknowledges the client's experience and promotes communication.
- Options B and C dismiss or deny the client's experience.
- Option D focuses on the cause rather
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspects which of the following types of anemia?
- A. Pernicious anemia
- B. Folic acid deficiency anemia
- C. Iron deficiency anemia
- D. Sickle cell anemia
Correct Answer: C
Rationale: The correct answer is C: Iron deficiency anemia. The client's low hemoglobin and hematocrit levels indicate a decrease in red blood cells, which is characteristic of anemia. Iron deficiency anemia is the most common type of anemia, typically caused by inadequate iron intake or absorption, leading to decreased production of hemoglobin. This results in symptoms like weakness, fatigue, and heavy menstrual periods, as seen in the client. Pernicious anemia (A) is due to vitamin B12 deficiency, not iron. Folic acid deficiency anemia (B) presents with similar symptoms but typically has normal iron levels. Sickle cell anemia (D) is a genetic disorder causing abnormal hemoglobin production, not related to iron deficiency.