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A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Irritability
- B. Euphoria
- C. Chronic pain
- D. Social withdrawal
- E. Changes in appetite
Correct Answer: A, C, D, E
Rationale: Depression in adolescents often presents with irritability, physical complaints (chronic pain), social withdrawal, and appetite changes.
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A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
- A. "Because you are a minor, I have to share any information that I feel is important with your parents."
- B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
- C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
- D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
Correct Answer: B
Rationale: Duty to warn applies when a client expresses intent to harm others, requiring disclosure to the care team.
A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?
- A. "Yes, I understand that you feel better wearing your bracelet."
- B. "Why do you think the copper helps with your arthritis?"
- C. "Believing objects have powers to make you feel better has no scientific basis."
- D. "I think you should rely more on your medication therapy than on your bracelet."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should acknowledge and validate the client's feelings and beliefs regarding the copper bracelet without dismissing them. By responding with empathy and understanding, the nurse can establish a trusting relationship with the client. This approach can lead to open communication and collaboration in the client's care. It is important to respect the client's perspective and provide support rather than judgment.
Incorrect Choices:
B: Asking the client why she thinks the copper helps may come off as dismissive or confrontational, potentially alienating the client.
C: Dismissing the client's beliefs outright can damage the nurse-client relationship and hinder effective communication.
D: Suggesting the client rely more on medication than the bracelet may be perceived as disregarding the client's preferences and autonomy in managing her condition.
A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Post a written schedule of daily activities
- B. Use an overhead loudspeaker to announce events
- C. Provide a consistent daily routine
- D. Allow the client to choose free-time activities
Correct Answer: C
Rationale: The correct answer is C: Provide a consistent daily routine. Individuals with Alzheimer's disease benefit from a structured routine as it helps reduce confusion and anxiety. Consistency in daily activities can enhance familiarity and comfort for the client, promoting a sense of security and predictability. This routine can also aid in maintaining the client's cognitive function and overall well-being.
Incorrect choices:
A: Post a written schedule of daily activities - While this may be helpful, a consistent routine is more effective in providing stability for individuals with Alzheimer's.
B: Use an overhead loudspeaker to announce events - Loud noises and sudden announcements can be overwhelming for individuals with Alzheimer's, causing distress.
D: Allow the client to choose free-time activities - While promoting autonomy is important, too many choices can lead to confusion and difficulty in decision-making for individuals with Alzheimer's.
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 in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
- A. Denial
- B. Displacement
- C. Projection
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of "I'm fine" despite having traumatic injuries indicate a defense mechanism of denial, where the client is refusing to acknowledge the severity of their situation. Denial helps the individual cope with overwhelming emotions or stress by avoiding the reality of the situation. Displacement involves redirecting emotions to a less threatening target, projection involves attributing one's thoughts or feelings to others, and undoing involves engaging in behaviors to counteract negative thoughts or actions. In this scenario, denial is the most appropriate reaction based on the client's behavior.