Nokea
A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse?
- A. The client is using manipulation to receive secondary gain.
- B. The client is using the defense mechanism of denial.
- C. The client is having trouble terminating the relationship.
- D. The client is using splitting as a way to remain dependent on the nurse.
Correct Answer: B
Rationale: The correct answer is B because the client's statement indicates denial of the upcoming change in nurses due to their belief that they are not well enough to switch. This defense mechanism helps the client avoid the reality of the situation. Choice A is incorrect as there is no evidence of manipulation for secondary gain. Choice C is incorrect as the client is not expressing difficulty in terminating the relationship. Choice D is incorrect as splitting involves seeing people as all good or all bad, which is not evident in the client's statement.
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During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development?
- A. Its hard for me to tell my story when Im not sure about the reactions of others.
- B. I think Joes Antabuse suggestion is a good one and might work for me.
- C. My situation is very complex, and I need professional, not peer, advice.
- D. I am really upset that you expect me to solve my own problems.
Correct Answer: B
Rationale: The correct answer is B because it shows the client actively engaging in problem-solving and considering specific strategies, indicating progress to the working phase. Choice A reflects the initial phase where trust and sharing are still developing. Choice C suggests a dependency on professional advice, not group collaboration. Choice D demonstrates resistance and a lack of ownership over personal growth, indicating an earlier phase of group development.
Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.
A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
- A. History of alcohol dependence
- B. History of personality disorder
- C. History of schizophrenia
- D. History of hypertension
Correct Answer: A
Rationale: The correct answer is A: History of alcohol dependence. Alprazolam is a benzodiazepine and can be addictive, especially for individuals with a history of substance abuse like alcohol dependence. This client population is at higher risk for misuse, addiction, and overdose. It is important for the nurse to question this order to avoid potential harm. Choices B, C, and D are incorrect as they do not directly impact the safety or efficacy of alprazolam for acute anxiety.
Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations?
- A. My sister has the same diagnosis as you and she also hears voices.
- B. I understand that the voices seem real to you, but I do not hear any voices.
- C. Why not turn up the radio so that the voices are muted.
- D. I wouldnt worry about these voices. The medication will make them disappear.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation without reinforcing the hallucinations. By acknowledging the client's experience while maintaining reality orientation, the nurse can build trust and rapport. Choice A may unintentionally normalize the hallucinations. Choice C could dismiss the client's experience and avoid addressing the underlying issue. Choice D minimizes the client's distress and relies solely on medication without addressing the client's emotional needs.