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A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Absence of impulsive behaviors.
- C. Involved in community activities.
- D. Submissive personality.
Correct Answer: A
Rationale: Low tolerance for frustration is a risk factor for becoming a perpetrator of child abuse as it can lead to impulsive and aggressive behaviors, increasing the likelihood of abusive actions.
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A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?
- A. Implement 24-hr one-to-one nursing observation.
- B. Document the client's behavior every 2 hr.
- C. Restrict interactions with other clients.
- D. Administer prescribed medication via the IM route.
Correct Answer: A
Rationale: Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm. This provides constant monitoring given the high-risk situation.
A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. I can discuss a client's information with staff who have provided care in the past.
- B. A client retains the legal right to privacy of health information even after they have died.
- C. The provider must give consent to discuss health information with the client's family.
- D. A provider may speak to a client's employer regarding a substance use disorder.
Correct Answer: B
Rationale: Clients retain the legal right to privacy of health information even after death, per HIPAA regulations. This statement reflects an accurate understanding of confidentiality principles.
A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.
A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?
- A. Reduction in hand tremors.
- B. Absence of seizures.
- C. Decreased hallucinations.
- D. Improved mood.
Correct Answer: D
Rationale: Fluoxetine, an SSRI, is expected to improve mood in clients with depression. This is its primary therapeutic effect, unlike reducing tremors or hallucinations.
A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?
- A. Reinforcing information on the potential adverse effects of a medication with the client.
- B. Encouraging the client to attend a daily exercise program on the unit.
- C. Respecting the client's right to refuse to attend a group therapy session.
- D. Maintaining the client's confidentiality about a substance use disorder.
Correct Answer: A
Rationale: Reinforcing information on the potential adverse effects of a medication demonstrates veracity, the principle of truthfulness. It ensures the client is fully informed, supporting ethical care and decision-making.