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A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing?
- A. Situational
- B. Maturational
- C. Adventitious
- D. Developmental
Correct Answer: A
Rationale: The correct answer is A: Situational crisis. This type of crisis occurs due to unexpected life events, such as the sudden death of a loved one, leading to feelings of overwhelm and inability to cope. In this case, the client's paralysis in handling work and family responsibilities aligns with the characteristics of a situational crisis. Other choices are incorrect because: B: Maturational crisis is related to normal life transitions, C: Adventitious crisis involves events like natural disasters, and D: Developmental crisis occurs during stages of life transition.
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A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make?
- A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."
- B. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable."
- C. "I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment."
- D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?"
Correct Answer: A
Rationale: Encouraging the parents to discuss their feelings helps with emotional processing and coping.
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?
- A. Decrease anxiety
- B. Prevent aggressive and impulsive behaviors
- C. Manipulate others
- D. Decrease the time available for interaction with people
Correct Answer: A
Rationale: The correct answer is A: Decrease anxiety. The repetitive cleaning behavior in OCD is a manifestation of the client's attempt to reduce anxiety caused by intrusive thoughts or obsessions. This behavior provides temporary relief from anxiety by creating a sense of control. Choice B is incorrect because OCD cleaning behaviors are not primarily aimed at preventing aggressive or impulsive behaviors. Choice C is incorrect as the cleaning behavior is not typically a form of manipulation. Choice D is incorrect as the primary goal of the behavior is not to decrease interaction time but to manage anxiety.
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 in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
- A. Recommend that the partner place the client in a long-term care facility.
- B. Suggest that the partner see a counselor to help him cope with his exhaustion.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Tell the partner to call a family meeting to get help.
Correct Answer: C
Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.
A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?
- A. The client will acknowledge alcohol dependence and need for treatment.
- B. The client will rebuild damaged interpersonal relationships.
- C. The client will implement alternative strategies for managing anxiety.
- D. The client's withdrawal from alcohol will be managed without complications.
Correct Answer: D
Rationale: The correct answer is D because managing alcohol withdrawal without complications is the highest priority to ensure the client's safety and well-being. Withdrawal from alcohol can lead to life-threatening complications such as seizures and delirium tremens. Addressing this goal first is crucial for stabilizing the client physically.
Choice A is important but not the highest priority as immediate physical safety takes precedence. Choices B and C are important for overall recovery but do not address the immediate risk of withdrawal complications.