Nokea
A nurse is providing teaching to a client who has an alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
- A. I am responsible for my alcoholism.
- B. I am powerless against my addiction to alcohol.
- C. I need to see a counselor who will be responsible for my recovery.
- D. I need to identify things that cause me to be an alcoholic.
Correct Answer: B
Rationale: Admitting powerlessness over alcohol aligns with AA’s first step.
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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. He is very religious and attends services twice a week.
- B. His cousin committed suicide a few weeks ago.
- C. He has slept 9 hours each night for the past 2 years.
- D. He spends much of his time with his two school friends.
Correct Answer: B
Rationale: The correct answer is B because a significant risk factor for suicide is having a close family member who has died by suicide. It indicates a potential increased vulnerability due to exposure to suicide and the impact of grief. Choice A (religious) and D (socially connected) are protective factors that can reduce suicide risk. Choice C (consistent sleep) is not directly related to suicide risk.
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.
A nurse is caring for a client diagnosed with schizophrenia. The client states,Did you know that I am engaged to the Prince of England? The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
- D. Control
Correct Answer: B
Rationale: The correct answer is B: Erotomanic delusion. This type of delusion involves the false belief that someone, typically of higher status or unreachable, is in love with the individual. In this case, the client believes they are engaged to the Prince of England, indicating an erotomanic delusion. Choice A: Persecution delusion involves believing one is being targeted or mistreated. Choice C: Somatic delusion involves beliefs about bodily functions. Choice D: Control delusion involves beliefs about external control. These are not applicable in the scenario described.
A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?
- A. A 45-year-old female who has a family history of autoimmune disorders
- B. A 73-year-old male who has an iodine deficiency
- C. A 25-year-old female who has metabolic syndrome
- D. A 35-year-old male who has Graves' disease
Correct Answer: D
Rationale: The correct answer is D: A 35-year-old male who has Graves' disease. Graves' disease is a common cause of hyperthyroidism characterized by an overactive thyroid gland. Individuals with Graves' disease often present with symptoms such as weight loss, tremors, and palpitations. The autoimmune nature of Graves' disease leads to the production of thyroid-stimulating immunoglobulins, resulting in excess thyroid hormone production. Therefore, a client with a known diagnosis of Graves' disease is at the highest risk for hyperthyroidism.
A: A 45-year-old female with a family history of autoimmune disorders may be at risk for developing autoimmune conditions, including hyperthyroidism, but without a current diagnosis of hyperthyroidism, she is not the most at risk in this scenario.
B: A 73-year-old male with iodine deficiency is more likely to develop hypothyroidism rather than hyperthyroidism, as iodine deficiency is a common cause
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
- A. Determining the cause of the client's anxiety
- B. Identifying the client's coping skills
- C. Protecting the client from injury to himself
- D. Ensuring that the client feels safe
Correct Answer: C
Rationale: The correct answer is C: Protecting the client from injury to himself. This is the highest priority because during a crisis intervention for acute anxiety, the client may be at risk of harming themselves. Ensuring their safety is crucial before addressing other needs. Option A is important but not the highest priority in this acute situation. Option B is relevant but not as urgent as ensuring safety. Option D is also important, but physical safety takes precedence over emotional safety.