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A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
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A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?
- A. Encouraging decision-making
- B. Playing a game of chess with the client
- C. Giving the client choices of activities
- D. Spending time sitting with the client
Correct Answer: D
Rationale: The correct answer is D: Spending time sitting with the client. This approach is therapeutic as it promotes a sense of companionship, support, and comfort for the client. By being present and engaged in the moment, the nurse can establish trust and demonstrate empathy towards the client, which are crucial in the treatment of severe depression. This approach also provides an opportunity for the client to express their feelings and thoughts in a safe and non-judgmental environment.
Choice A, encouraging decision-making, may overwhelm the client who is dealing with severe depression and may exacerbate their feelings of helplessness. Choice B, playing a game of chess, may be too stimulating or competitive for the client in this vulnerable state. Choice C, giving the client choices of activities, may add unnecessary pressure and decision-making burden on the client. Overall, spending time sitting with the client is the most appropriate and therapeutic nursing approach in this scenario.
A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make?
- A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."
- B. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable."
- C. "I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment."
- D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?"
Correct Answer: A
Rationale: Encouraging the parents to discuss their feelings helps with emotional processing and coping.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
- A. Difficulty relaxing
- B. Irrational fear of certain objects
- C. Rule-conscious behavior
- D. Unaware of compulsions
- E. Perfectionist behavior
Correct Answer: A, B, C, E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Difficulty relaxing is an expected finding in OCD due to persistent intrusive thoughts causing anxiety and tension.
B: Irrational fear of certain objects is common in OCD, leading to compulsive behaviors to reduce anxiety.
C: Rule-conscious behavior is a characteristic of OCD where individuals feel compelled to follow specific routines or rules.
E: Perfectionist behavior is a common trait in OCD as individuals strive for perfection to alleviate anxiety.
Incorrect Choices:
D: Individuals with OCD are usually aware of their compulsions, distinguishing them from other disorders.
F, G: No additional choices provided.
Summary:
The correct answers (A, B, C, E) align with the typical symptoms of OCD, including anxiety, compulsions, rule-following, and perfectionism. The incorrect choices (D, F, G) do not accurately reflect the expected findings in OCD.
A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. "Tell me about the concerns that you have regarding your relationship."
- B. "You should try to see your partner’s point of view before your own."
- C. "We could develop a plan for how to talk about this with your partner."
- D. "Relationship difficulties are stressful and require effort to resolve."
Correct Answer: B
Rationale: The correct answer is B. This statement implies a bias towards the partner's perspective, potentially invalidating the client's feelings. The nurse should prioritize understanding the client's concerns first. A is correct as it encourages open communication. C shows proactive problem-solving. D acknowledges the challenges of resolving relationship issues.
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
- A. Recommend that the partner place the client in a long-term care facility.
- B. Suggest that the partner see a counselor to help him cope with his exhaustion.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Tell the partner to call a family meeting to get help.
Correct Answer: C
Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.