Nokea
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. Involved in community activities.
- C. Submissive personality.
- D. Absence of impulsive behaviors.
Correct Answer: A
Rationale: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms.
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A nurse is caring for a client who has an anxiety disorder and reports ongoing difficulty sleeping at night. Which of the following recommendations should the nurse make?
- A. Drink 5 ounces of red wine roughly 30 minutes before bed.
- B. Limit caffeine to one or two servings during daytime hours.
- C. Exercise 1 hour before bedtime.
- D. Stay in bed for 1 hour before getting up if you are unable to sleep.
Correct Answer: B
Rationale: Limiting caffeine intake to one or two servings during daytime hours is a beneficial recommendation for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep. By reducing caffeine consumption and avoiding it in the late afternoon and evening, individuals can enhance their chances of achieving restful sleep.
A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?
- A. You will be given an opioid analgesic before the procedure.
- B. Expect to be confused several hours after the procedure.
- C. You cannot eat or drink for 24 hours before the procedure.
- D. A consent form is not required to have this procedure.
Correct Answer: B
Rationale: Confusion and temporary memory loss are common side effects immediately following ECT. Clients should be informed to expect these cognitive effects, which can last for a few hours to days. Educating the client about these side effects helps prepare them for what to expect post-procedure and ensures they have appropriate support during their recovery period.
A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?
- A. Unable to make simple decisions
- B. Enjoys spending time alone
- C. Exhibits extreme perfectionism
- D. Displays confrontational behavior
Correct Answer: A
Rationale: Individuals with dependent personality disorder often struggle with making simple decisions without excessive advice and reassurance from others. They have a strong need for others to take responsibility for major areas of their lives and can feel helpless when alone. This indecisiveness is a hallmark of the disorder and stems from their lack of self-confidence and reliance on others for guidance and support.
A nurse is reinforcing teaching with a client about naltrexone. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will not experience alcohol withdrawal if I take this medication.
- B. The medication will allow me to gradually decrease my alcohol intake.
- C. If I drink alcohol with this medication, I will experience ringing in my ears.
- D. Taking this medication will reduce my cravings for alcohol.
Correct Answer: D
Rationale: This statement accurately reflects one of the primary effects of naltrexone. The medication helps reduce cravings for alcohol, making it easier for individuals to maintain abstinence and avoid relapse. By understanding this aspect of naltrexone, the client demonstrates a clear understanding of its purpose and use in alcohol dependence treatment.
A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says
- A. I heard that Mr. Smith was admitted for a suicide attempt. Which of the following responses should the charge nurse make?
- B. I will be informing the provider about this conversation.
- C. You should continue this conversation in a private place.
- D. It is an invasion of privacy to discuss that information.
- E. If you are going to talk about a client in public, do not use their name.
Correct Answer: C
Rationale: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.