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A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following actions should be included in the plan of care?
- A. Allow manipulation so as to not raise the client’s anxiety.
- B. Avoid discussing past behaviors with the client.
- C. Bargain with the client to discourage manipulative behavior.
- D. Set clear and consistent limits on manipulative behaviors.
Correct Answer: D
Rationale: The correct answer is D: Set clear and consistent limits on manipulative behaviors. By setting clear boundaries, the nurse establishes a structured environment that promotes accountability and helps the client understand appropriate behavior. This method reinforces boundaries and helps the client learn to interact in a healthier way.
Explanation for other choices:
A: Allowing manipulation does not address the underlying issue and may enable further manipulative behavior.
B: Avoiding discussing past behaviors hinders the therapeutic process and may prevent understanding and resolution of manipulative tendencies.
C: Bargaining with the client only reinforces manipulative behavior and does not address the root cause.
In summary, setting clear and consistent limits is the most effective approach in managing manipulative behavior.
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A school nurse is speaking to the mother of a 16-year-old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?
- A. "His favorite teacher committed suicide a few weeks ago."
- B. "He has slept 9 hours each night for the past 2 years."
- C. "He is very religious and attends services twice a week."
- D. "He spends much of his time with his two school friends."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The statement "His favorite teacher committed suicide a few weeks ago" indicates exposure to suicide, which is a risk factor for suicidal behavior. This experience can trigger feelings of hopelessness and increase the risk of suicide in adolescents. The mother's concern in this context is valid and should be taken seriously.
Summary:
B: Sleeping 9 hours each night for the past 2 years is not a direct indicator of suicide risk. While changes in sleep patterns can be a sign of depression, it is not as specific as exposure to suicide.
C: Being religious and attending services twice a week is not necessarily an indicator of suicide risk. Religious beliefs can provide comfort and support.
D: Spending time with friends is generally a positive sign of social connectedness, which can be protective against suicide.
A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?
- A. "Yes, I understand that you feel better wearing your bracelet."
- B. "Why do you think the copper helps with your arthritis?"
- C. "Believing objects have powers to make you feel better has no scientific basis."
- D. "I think you should rely more on your medication therapy than on your bracelet."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should acknowledge and validate the client's feelings and beliefs regarding the copper bracelet without dismissing them. By responding with empathy and understanding, the nurse can establish a trusting relationship with the client. This approach can lead to open communication and collaboration in the client's care. It is important to respect the client's perspective and provide support rather than judgment.
Incorrect Choices:
B: Asking the client why she thinks the copper helps may come off as dismissive or confrontational, potentially alienating the client.
C: Dismissing the client's beliefs outright can damage the nurse-client relationship and hinder effective communication.
D: Suggesting the client rely more on medication than the bracelet may be perceived as disregarding the client's preferences and autonomy in managing her condition.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
- A. Administer diazepam.
- B. Raise the side rails of the bed.
- C. Obtain a medical history.
- D. Start intravenous fluids.
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and is now pacing up and down the corridors of the unit. Which of the following actions should the nurse take?
- A. Instruct the client to sit down and stop pacing.
- B. Allow the client to pace alone until physically tired.
- C. Have a staff member escort the client to her room.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: Walking with the client helps provide support while allowing them to work through their anxiety.
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?
- A. Alcohol
- B. Caffeine
- C. Cocaine
- D. Inhalants
Correct Answer: A
Rationale: Chronic alcohol use is the leading cause of liver cirrhosis due to its toxic effects on liver cells.