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A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states,I'm frightened. Do you hear that? The voices are telling me to do terrible things. Which of the following responses by the nurse is appropriate?
- A. What are the voices telling you to do?
- B. You need to tell the voices to leave you alone.
- C. You need to understand that there are no voices.
- D. Why do you think you are hearing the voices?
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. **Acknowledge the client's experience**: By asking "What are the voices telling you to do?" the nurse validates the client's experience and shows empathy.
2. **Encourages communication**: This response opens up a dialogue and allows the nurse to gather more information for assessment and understanding.
3. **Avoids dismissing or denying the experience**: Options B and C dismiss or deny the existence of the voices, which can make the client feel unheard or misunderstood.
4. **Promotes therapeutic communication**: Asking about the content of the voices helps the nurse assess the client's level of distress and potential risk.
5. **Supports building trust**: By demonstrating active listening and showing interest in the client's experience, the nurse can build a trusting therapeutic relationship.
Summary:
- Option A is correct as it acknowledges the client's experience and promotes communication.
- Options B and C dismiss or deny the client's experience.
- Option D focuses on the cause rather
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During a group therapy meeting,a client brings up a concern about the cleanliness of the bathroom. The nurse asks the group what should be done about the issue and how to resolve it. The nurse is demonstrating which type of leadership style?
- A. Laissez-faire
- B. Surrogate
- C. Autocratic
- D. Democratic
Correct Answer: D
Rationale: The correct answer is D: Democratic. In a democratic leadership style, the leader involves group members in decision-making. In this scenario, the nurse is asking the group for input and involving them in the process of resolving the issue, which aligns with the democratic approach. This empowers the group members to participate in finding a solution and promotes teamwork.
A: Laissez-faire is incorrect because in this style, the leader is hands-off and does not provide much guidance or direction.
B: Surrogate is incorrect as it refers to a substitute leader who takes over temporarily.
C: Autocratic is incorrect because in this style, the leader makes decisions without consulting the group.
Overall, the democratic leadership style is the most suitable for fostering collaboration and addressing group concerns effectively in this context.
Claudette, the nurse, is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication
- A. I feel angry when you leave me.
- B. I wish you would not make me angry.
- C. It makes me angry when you interrupt me.
- D. You'd better listen to me.
Correct Answer: D
Rationale: The correct answer is D because it is an example of aggressive communication. The statement "You'd better listen to me" is forceful, directive, and implies a threat if the listener does not comply. This type of communication lacks respect for the other person's feelings and boundaries. In contrast, choices A, B, and C express personal feelings and thoughts without being demanding or confrontational. Choice A uses "I feel" to express emotions, choice B expresses a wish without placing blame, and choice C explains a reaction to a specific behavior without being forceful. Therefore, D stands out as the only example of aggressive communication in the given options.
The nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate?
- A. Xerostomia
- B. Bradycardia
- C. Epistaxis
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Epistaxis. Disseminated Intravascular Coagulation (DIC) is a condition where the body's clotting system is overactive, leading to both excessive clot formation and clot breakdown. Epistaxis, or nosebleeds, is a common physical finding in DIC due to the depletion of clotting factors and platelets. Xerostomia (A) is dry mouth and not typically associated with DIC. Bradycardia (B) is a slow heart rate, which is not a common finding in DIC as it usually presents with tachycardia. Hypertension (D) is increased blood pressure, which is not a typical physical finding in DIC.
A nurse is educating a 28-year-old female client about the impacts of hypothyroidism on overall health. Which of the following statements would the nurse include in the teaching?
- A. If you become pregnant, low thyroid hormone levels can affect your developing fetus.
- B. Hypothyroidism can cause autoimmune disorders over time.
- C. Low thyroid hormone levels will cause your metabolism to speed up and heart rate to increase.
- D. Low blood pressure is usually associated with hypothyroidism.
Correct Answer: A
Rationale: Rationale: The correct answer is A because hypothyroidism, characterized by low thyroid hormone levels, can lead to complications during pregnancy, affecting fetal development. This is due to the essential role of thyroid hormones in fetal brain and nervous system development.
Summary of Incorrect Choices:
B: Hypothyroidism is linked to autoimmune disorders, not a consequence of it.
C: Hypothyroidism actually slows down metabolism and heart rate due to decreased thyroid hormone levels.
D: Low blood pressure is more commonly associated with hyperthyroidism, where the thyroid is overactive.
A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate the client is experiencing maladaptive grief?
- A. The client meets his daughter for dinner every week.
- B. The client joined a bowling league 2 months ago.
- C. The client exercises at a local health facility 3 days each week.
- D. The client has kept his partner's closet untouched since her death.
Correct Answer: D
Rationale: The correct answer is D because keeping the partner's closet untouched after five years indicates a lack of acceptance and inability to move forward in the grieving process, suggesting maladaptive grief. Choice A shows social support, B reflects engagement in a new activity, and C indicates a healthy coping mechanism through exercise.