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A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of a maturational crisis?
- A. Loss of job.
- B. Motor-vehicle crash.
- C. Divorce.
- D. A child leaving for college.
Correct Answer: D
Rationale: A child leaving for college represents a maturational crisis, tied to normal developmental transitions that cause stress. Unlike situational crises like job loss or divorce, it reflects life stage changes.
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A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse
- A. This baby constantly cries. My partner works all the time
- B. and I can't take any more.' Which of the following responses is the nurse’s priority?
- C. Have you discussed this with your partner.
- D. Do you have a friend who could help you.
- E. Tell me about your baby.
- F. Have you tried any soothing techniques for your baby.
Correct Answer: C
Rationale: Asking about the baby’s current condition immediately assesses safety and well-being, which is the nurse’s priority. This ensures potential risks, like postpartum depression or infant harm, are addressed first.
A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?
- A. Provide the client with a dark environment for sleeping.
- B. Repeat orientation tasks until the client gives a correct response.
- C. Give the client a list of foods to choose from for dinner.
- D. Make a personal introduction to the client at each interaction.
Correct Answer: D
Rationale: Making a personal introduction at each interaction helps establish connection and reduce confusion for clients with dementia, who often have short-term memory loss.
A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect?
- A. Preoccupation with details.
- B. Manipulative behaviors.
- C. Impulsiveness.
- D. Splitting.
Correct Answer: B
Rationale: Manipulative behaviors are a common finding in individuals with antisocial personality disorder. These individuals often use manipulation to gain control or achieve their own goals without regard for others, aligning with the disorder’s characteristics.
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 in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. Currently married.
- B. Access to guns in the home.
- C. Terminal liver cancer.
- D. Alcohol use disorder.
Correct Answer: B,C,D
Rationale: Access to guns in the home, terminal liver cancer, and alcohol use disorder are significant risk factors for suicide. Guns increase lethality, terminal illness causes distress, and alcohol impairs judgment and increases impulsivity, all elevating suicide risk.