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A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
- A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
- B. I wont stop taking this medication abruptly, because there could be serious complications.
- C. I will not drink alcohol while taking this medication.
- D. I wont take extra doses of this drug because I can become addicted.
Correct Answer: A
Rationale: The correct answer is A because the statement indicates a misunderstanding. Benzodiazepines do not require routine blood monitoring for toxicity. Benzodiazepines are typically monitored based on clinical response and potential side effects. Choices B, C, and D are all correct statements related to benzodiazepine use, emphasizing the importance of not abruptly stopping the medication, avoiding alcohol, and not taking extra doses to prevent addiction.
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An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?
- A. Encourage exploration of sexual abuse
- B. Encourage guided imagery
- C. Establish trust and rapport
- D. Administer antianxiety medications
Correct Answer: C
Rationale: The correct answer is C: Establish trust and rapport. This is the priority because building a therapeutic relationship is essential for effective treatment of DID. Trust and rapport are foundational for the client to feel safe and supported in exploring and processing traumatic experiences. Encouraging exploration of sexual abuse (Option A) may be overwhelming and retraumatizing without a solid therapeutic alliance. Guided imagery (Option B) might not be appropriate at this stage as the client needs to establish trust first. Administering antianxiety medications (Option D) alone does not address the root cause or provide the necessary support for the client's complex trauma history.
A nurse is caring for a hospitalized client who is quarrelsome and opinionated and has little regard for others. According to Sullivans interpersonal theory, the nurse should associate the clients behaviors with a previous deficit in which stage of development?
- A. Childhood
- B. Early adolescence
- C. Late adolescence
- D. Infancy
Correct Answer: A
Rationale: According to Sullivan's interpersonal theory, childhood is the stage where the foundation of interpersonal relationships is formed. Quarrelsome and opinionated behaviors with little regard for others can be associated with deficits in early childhood development. During this stage, individuals learn emotional regulation, empathy, and social skills. If these skills are not adequately developed in childhood, it can result in maladaptive behaviors in adulthood. Therefore, the correct answer is A.
Choice B, early adolescence, focuses more on identity formation and peer relationships. Choice C, late adolescence, emphasizes the transition to adulthood and independence. Choice D, infancy, is too early in development to have a significant impact on the client's current behavior.
Which rationale by a nursing instructor best explains why it is challenging to globally classify the Asian American culture?
- A. Extremes of emotional expression prevent accurate assessment of this culture.
- B. Suspicion of Western civilization has resulted in minimal cultural research.
- C. The small size of this subpopulation makes research virtually impossible.
- D. The Asian American culture includes individuals from many different countries.
Correct Answer: D
Rationale: The correct answer is D because the Asian American culture is not monolithic but comprises individuals from diverse Asian countries with unique customs, languages, and traditions. This diversity makes it challenging to globally classify the culture as a whole. Option A is incorrect as emotional expression varies within Asian American communities. Option B is incorrect as there has been cultural research on Asian Americans. Option C is incorrect as the size of the population does not hinder research efforts.
To promote self-reliance, how should a psychiatric nurse best conduct medication administration?
- A. Encourage clients to request their medications at the appropriate times.
- B. Refuse to administer medications unless clients request them at the appropriate times.
- C. Allow the clients to determine appropriate medication times.
- D. Take medications to the clients bedside at the appropriate times.
Correct Answer: A
Rationale: The correct answer is A because it promotes self-reliance by empowering clients to take responsibility for their own medication schedule. By encouraging clients to request their medications at the appropriate times, the nurse fosters autonomy and self-management.
Choice B is incorrect as it is too extreme and may compromise client safety by withholding medications based solely on client request. Choice C is incorrect as it puts the responsibility solely on the client without appropriate guidance from the nurse. Choice D is incorrect as it does not actively involve the client in the medication administration process.
An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
- A. The employee assertively confronts the boss
- B. The employee leaves the staff meeting to work out in the gym
- C. The employee criticizes a coworker
- D. The employee takes the boss out to lunch
Correct Answer: C
Rationale: Displacement is a defense mechanism where emotions are redirected from the original source to a substitute target. In this case, the employee is likely to displace their anger from the boss onto a coworker by criticizing them. This behavior allows the employee to express their feelings indirectly.
A: Assertively confronting the boss does not align with displacement as it involves direct confrontation.
B: Leaving the meeting to work out in the gym is a form of avoidance and does not involve displacing emotions onto another target.
D: Taking the boss out to lunch is more of a conciliatory gesture and does not involve displacing negative emotions onto someone else.