Nokea
A nurse is counseling an adult client whose parent just died. The client states, 'My son is 4, and I don’t know how he’ll react when he finds out that grandpa died.' The nurse should inform the client that the preschool-age child commonly has which of the following concepts of death?
- A. Death is not permanent and the loved one may come back to life
- B. Death is contagious and can cause other people he loves to die
- C. Death creates an interest in the physical aspects of dying
- D. Death is a part of life that eventually happens to everyone
Correct Answer: A
Rationale: The correct answer is A: Death is not permanent and the loved one may come back to life. Preschool-age children often have an understanding of death as temporary, believing that the deceased may come back to life. This is due to their cognitive development and limited understanding of the finality of death. Other choices are incorrect: B is incorrect as children do not typically view death as contagious; C is incorrect as preschoolers often lack a detailed interest in the physical aspects of dying; D is incorrect as preschoolers may not fully grasp the concept of death being a natural part of life.
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A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder?
- A. I will limit my mother’s clothing choices when she is getting dressed
- B. I will provide my mother with detailed instructions about how to perform self-care
- C. I will wake my mother up a couple of times in the night to check on her
- D. I will discourage my mother from talking about physical complaints
Correct Answer: B
Rationale: The correct answer is B: "I will provide my mother with detailed instructions about how to perform self-care." This statement indicates an understanding of obsessive-compulsive disorder (OCD) because individuals with OCD often struggle with performing daily tasks due to their obsessive thoughts and compulsive behaviors. By providing detailed instructions, the daughter is acknowledging the need for structured routines to help her mother manage her symptoms.
A: Limiting clothing choices does not address the underlying issues of OCD and may exacerbate anxiety.
C: Waking the mother up to check on her reinforces compulsions, which is counterproductive in treating OCD.
D: Discouraging the mother from talking about physical complaints does not address the core symptoms of OCD.
By choosing option B, the daughter shows insight into the importance of providing support and guidance in managing the challenges associated with OCD.
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?
- A. Discourage the client from expressing feelings of anger
- B. Identify and schedule alternative group activities for the client
- C. Encourage physical activity for the client during the day
- D. Keep a bright light on in the clients room at night
Correct Answer: C
Rationale: The correct answer is C: Encourage physical activity for the client during the day. Physical activity has been shown to improve mood and reduce symptoms of depression by increasing endorphins. This intervention can help the client combat feelings of sadness and hopelessness.
A: Discouraging the client from expressing feelings of anger is not therapeutic and may further suppress emotions, worsening depression.
B: Identifying and scheduling alternative group activities can be helpful, but it may not directly address the physical aspect of depression.
D: Keeping a bright light on in the client's room at night may disrupt sleep patterns and is not a targeted intervention for major depressive disorder.
A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?
- A. Schizoid personality disorder
- B. Alcohol intoxication
- C. Dysthymic disorder
- D. Long-term isolation
Correct Answer: B
Rationale: The correct answer is B: Alcohol intoxication. Alcohol intoxication can impair judgment, lower inhibitions, and increase aggression, leading to a higher risk of violent behavior. Schizoid personality disorder (A) is characterized by social detachment, not necessarily violence. Dysthymic disorder (C) involves chronic low mood but not a direct risk for violent behavior. Long-term isolation (D) may contribute to mental health issues but does not directly indicate violent behavior.
A nurse is planning care for a client who has bipolar disorder and is experiencing a depressive episode. Which of the following interventions should the nurse include?
- A. Encourage excessive physical activity
- B. Provide frequent rest periods
- C. Discourage interaction with others
- D. Implement a rigid daily routine
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During a depressive episode in bipolar disorder, the client may experience fatigue and lack of motivation. Providing frequent rest periods allows for adequate relaxation and helps to conserve energy. This intervention supports the client in managing their symptoms and promotes self-care.
A: Encouraging excessive physical activity may exacerbate fatigue and worsen symptoms during a depressive episode.
C: Discouraging interaction with others may increase feelings of isolation and worsen depressive symptoms.
D: Implementing a rigid daily routine may add pressure and stress to the client, which can be counterproductive during a depressive episode.
A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other children in the unit. Which of the following actions should the nurse take first?
- A. Place the child in seclusion
- B. Use therapeutic hold technique
- C. Apply wrist restraints
- D. Administer risperidone
Correct Answer: A
Rationale: The correct answer is A: Place the child in seclusion. The first step in managing physically aggressive behavior in a child with conduct disorder is to ensure the safety of the child and others. Placing the child in seclusion helps prevent harm to others while allowing the child to calm down in a controlled environment. Using therapeutic hold technique (B) or applying wrist restraints (C) may escalate the situation and increase the risk of harm. Administering risperidone (D) is a medication intervention that should be considered only after addressing the immediate safety concerns.