Nokea
A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?
- A. Let's discuss what you mean when you say that you cannot ever return to work.
- B. You need to work hard on resolving conflict with those closest to you.
- C. Antidepressants are not your solution, but this therapy group is.
- D. I notice you keep clenching your fists. Why are you doing this?
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A demonstrates active listening and encourages further exploration of the client's feelings and perspectives. It shows empathy and promotes open communication. It allows the nurse to understand the client's concerns about returning to work and address them effectively.
Summary:
B: This choice is not appropriate as it focuses on resolving interpersonal conflicts rather than addressing the client's concerns about their diagnosis.
C: This choice dismisses the potential need for medication and minimizes the importance of therapeutic support.
D: This choice addresses a physical behavior without directly addressing the client's emotional concerns about work.
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A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?
- A. The client responds to questions with disorganized speech.
- B. The client has lost interest in sexual relations.
- C. The client reports that voices are telling him to write a novel.
- D. The client's spouse reports that the client has recently gained weight.
Correct Answer: A
Rationale: The correct answer is A because responding to questions with disorganized speech is a common symptom of acute mania in bipolar disorder. This symptom is indicative of the manic phase, where individuals often exhibit pressured speech, flight of ideas, and tangential thinking. Choice B, loss of interest in sexual relations, is more associated with depression than mania. Choice C, hearing voices instructing to write a novel, is more suggestive of psychosis rather than mania. Choice D, weight gain, is not a specific symptom of acute mania.
A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Ritualistic behavior
- B. Short attention span
- C. Spinning a toy repetitively
- D. Consistent limit testing
- E. Delayed language development
Correct Answer: A,B,C,E
Rationale: The correct findings for a child with autism spectrum disorder are A, B, C, and E. A: Ritualistic behavior is common in children with ASD due to their need for predictability and routine. B: Short attention span is often seen in children with ASD, affecting their ability to focus on tasks. C: Spinning a toy repetitively is a stereotypical behavior associated with ASD, serving as a self-soothing mechanism. E: Delayed language development is a hallmark feature of ASD, impacting communication skills. These findings align with the core characteristics of ASD. Choices D and beyond are incorrect as they do not typically align with common manifestations of ASD in children.
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?
- A. The client eats red meat daily.
- B. The client has had gastric bypass surgery.
- C. The client has had treatment for gastrointestinal cancer.
- D. The client eats mostly prepackaged,processed foods.
- E. The client has ulcerative colitis.
Correct Answer: B,C,D,E
Rationale: The correct answer includes choices B, C, D, and E. Gastric bypass surgery can lead to malabsorption of iron, increasing the risk of anemia. Treatment for gastrointestinal cancer can also affect iron absorption. Eating mostly prepackaged, processed foods may lack iron-rich foods, contributing to anemia risk. Ulcerative colitis can cause intestinal bleeding, leading to iron deficiency. Choice A is incorrect as red meat is a good source of iron.
A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?
- A. I exercise when my neck is tense.
- B. I fix myself a pot of coffee when I get anxious.
- C. I pray when I begin to breathe fast.
- D. I journal when I find it difficult to talk.
Correct Answer: B
Rationale: The correct answer is B. Fixing oneself a pot of coffee when feeling anxious is the least effective stress management technique mentioned. Caffeine in coffee can exacerbate anxiety symptoms due to its stimulant properties, leading to increased heart rate and jitteriness. Exercise (A) helps release tension, prayer (C) promotes relaxation, and journaling (D) aids in expressing emotions. Choosing coffee over these more beneficial techniques can be counterproductive in managing stress.
A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?
- A. Since his mother died, he has not been feeling well.
- B. My husband just didn't seem to know what he was doing. He has been forgetful for years.
- C. The changes in his behavior came on so quickly! I wasn't sure what was happening.
- D. This is supposed to happen when you get old, right?
Correct Answer: C
Rationale: The correct answer is C because delirium is characterized by a rapid onset of confusion, changes in behavior, and altered mental status. The wife's statement about the changes in behavior coming on quickly aligns with this key characteristic of delirium.
Choice A is incorrect because the client's feelings after his mother's death are not necessarily related to delirium. Choice B is incorrect because long-term forgetfulness is more indicative of dementia rather than delirium. Choice D is incorrect because delirium is not a normal part of aging.