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A nurse is providing teaching to the caregiver of a client who has schizophrenia. Which of the following statements by the caregiver indicates an understanding of the teaching?
- A. I should reinforce reality when my loved one is experiencing delusions.'
- B. I should discourage my loved one from expressing feelings.'
- C. I should avoid talking to my loved one about his hallucinations.'
- D. I should encourage my loved one to isolate when symptoms occur.'
Correct Answer: A
Rationale: The correct answer is A: "I should reinforce reality when my loved one is experiencing delusions." This statement indicates an understanding of the teaching because it aligns with the therapeutic approach of reality orientation, which helps the client differentiate between reality and delusions. By reinforcing reality, the caregiver can help the client manage their symptoms effectively.
Choices B, C, and D are incorrect because they promote behaviors that are not beneficial for a client with schizophrenia. Discouraging the expression of feelings (B) can lead to emotional suppression. Avoiding discussion about hallucinations (C) may prevent the caregiver from understanding the client's experiences. Encouraging isolation (D) can worsen symptoms and hinder social interaction, which is important for recovery.
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A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
- A. I don’t know how I could cope if I didn’t have my family’s support
- B. It’ll be a long time before I’m happy again
- C. I don’t feel anything but numbness anymore
- D. I feel like I’m angry at the whole world right now
Correct Answer: C
Rationale: The correct answer is C: "I don’t feel anything but numbness anymore." This statement indicates a significant emotional numbness, which is a common symptom of clinical depression. It suggests a lack of normal emotional responses, which can be concerning.
Choice A does not specifically indicate clinical depression but rather expresses a need for support. Choice B reflects a natural response to grief and does not necessarily indicate depression. Choice D suggests anger, which can also be a normal part of the grieving process.
In summary, Choice C is the correct answer as it directly points to a key symptom of clinical depression, while the other choices reflect common emotional responses to grief that may not necessarily indicate depression.
A nurse in a community clinic is planning an educational session for a group of clients. Which of the following strategies should the nurse use when teaching about stress management?
- A. Provide lengthy lectures on stress
- B. Encourage discussion and practice of coping skills
- C. Discourage clients from expressing emotions
- D. Teach all clients the same stress-reduction technique
Correct Answer: B
Rationale: The correct answer is B: Encourage discussion and practice of coping skills. This strategy is effective because it actively engages clients in learning and applying coping mechanisms, promoting better retention and skill development. By encouraging discussion, clients can share experiences and support each other, enhancing their understanding and motivation. Practicing coping skills helps clients to internalize and apply them in real-life situations.
Incorrect choices:
A: Providing lengthy lectures is less effective as it can be overwhelming and may not actively involve clients in learning.
C: Discouraging clients from expressing emotions hinders the therapeutic process and can lead to bottling up emotions, increasing stress.
D: Teaching all clients the same technique may not address individual needs and preferences, limiting the effectiveness of stress management strategies.
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
- A. Rationalization
- B. Denial
- C. Compensation
- D. Displacement
Correct Answer: C
Rationale: The client is demonstrating the defense mechanism of Compensation. Compensation involves covering up weaknesses by emphasizing strengths in other areas. In this scenario, the client is compensating for feeling inadequate or unappreciated by becoming angry and defensive when his actions are questioned. This behavior serves to divert attention away from his perceived shortcomings and protect his self-esteem.
Rationalization (A) involves creating logical explanations to justify behaviors or feelings. Denial (B) is refusing to acknowledge unpleasant realities. Displacement (D) is redirecting emotions from the real target to a substitute target. In this case, these defense mechanisms are not as applicable as Compensation, which directly relates to the client's behavior of overcompensating for his perceived lack of attention.
A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect?
- A. Self-mutilation
- B. Pacing back and forth
- C. Preoccupation with details
- D. Disorganized speech
Correct Answer: A
Rationale: The correct answer is A: Self-mutilation. Individuals with borderline personality disorder often engage in self-harming behaviors as a way to cope with intense emotions or distress. This behavior is a common manifestation of the disorder and requires careful monitoring and intervention by the nurse.
Incorrect Choices:
B: Pacing back and forth - This behavior is more commonly associated with anxiety or agitation rather than specifically with borderline personality disorder.
C: Preoccupation with details - While individuals with borderline personality disorder may display perfectionistic tendencies, preoccupation with details is not a defining characteristic of the disorder.
D: Disorganized speech - Disorganized speech is more commonly seen in conditions such as schizophrenia, rather than borderline personality disorder.
A nurse is assessing a client who has opioid withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Hyperthermia
- C. Insomnia
- D. Bradycardia
Correct Answer: C
Rationale: The correct answer is C: Insomnia. Opioid withdrawal often presents with symptoms like insomnia due to increased sympathetic activity. Hypotension (A) is less likely as opioids can cause hypertension. Hyperthermia (B) is not typically associated with opioid withdrawal. Bradycardia (D) is also less common, as opioid withdrawal can lead to tachycardia. Insomnia is a hallmark symptom of opioid withdrawal, making it the most appropriate choice.