Nokea
A nurse is collecting data from a client who has been admitted with manifestations of paranoia. Which of the following findings should the nurse identify as a risk factor for schizophrenia?
- A. The client's home has lead paint on the walls.
- B. The client's twin sibling has schizophrenia.
- C. The client is opioid dependent.
- D. The client's mother used tobacco products during pregnancy.
Correct Answer: B
Rationale: Having a family member, especially a twin sibling, with schizophrenia significantly increases the risk of developing the condition. Genetics play a crucial role in the development of schizophrenia, and individuals with a first-degree relative who has schizophrenia are at a higher risk of developing the disorder.
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A nurse is caring for a client who has a phobia of elevators. Which of the following behavioral strategies should the nurse plan to use to decrease anxiety?
- A. Response prevention.
- B. Systematic desensitization.
- C. Thought stopping.
- D. Flooding.
Correct Answer: B
Rationale: Systematic desensitization is an effective behavioral strategy for decreasing anxiety related to specific phobias. This method involves gradually exposing the client to the feared object or situation—in this case, elevators—in a controlled and progressive manner while teaching relaxation techniques. By slowly and systematically confronting the phobia, the client can learn to reduce their anxiety response over time.
A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?
- A. Inform the parents that the findings must be reported to authorities.
- B. Complete an incident report for risk management.
- C. Interview the child about the suspected abuse with a parent present.
- D. Avoid asking the child what caused the injury.
Correct Answer: A
Rationale: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.
A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?
- A. Serum creatinine.
- B. Thiamine level.
- C. Urinalysis.
- D. Erythrocyte sedimentation rate.
Correct Answer: B
Rationale: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.
A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?
- A. The client goes to their room alone when they feel overwhelmed.
- B. The client displaces their feelings of self-harm until they talk to the provider.
- C. The client suppresses their feelings when they are angry.
- D. The client notifies the nurse when they want to harm themselves.
Correct Answer: D
Rationale: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.
A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?
- A. I remember how depressed I was after my friend died.
- B. You should start participating in your usual activities.
- C. Everyone feels depressed during the grieving process.
- D. Tell me what your relationship with your partner was like.
Correct Answer: D
Rationale: This response opens a conversation about the client’s feelings and experiences, showing empathy and a willingness to understand their perspective. It helps build trust and rapport, allowing the nurse to provide appropriate support.