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A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality.
- B. leaving the client alone until reality returns.
- C. asking the client to describe what is happening.
- D. telling the client there are no voices.
Correct Answer: C
Rationale: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.
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A client recently lost a child due to poisoning. The client tells the nurse, 'I don't want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional behavioral indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The client's withdrawal from forming new relationships reflects a sociocultural indicator of stress, as it affects social interactions. Emotional behavioral indicators involve mood changes, spiritual indicators relate to existential concerns, and intellectual indicators involve cognitive difficulties.
In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:
- A. whole brain death.
- B. heart-lung death.
- C. circulatory death.
- D. higher brain death.
Correct Answer: A
Rationale: Most protocols require two separate clinical examinations, including induction of painful stimuli, papillary responses to light, oculovestibular testing, and apnea testing. Heart-lung and higher brain death have no specific test required. Circulatory death is not a current definition of death in the United States.
A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions
- B. making a baseline record of the time the wife spends cleaning
- C. decreasing the stimuli in the home
- D. helping his wife with the cleaning
Correct Answer: C
Rationale: Reducing environmental stimuli can decrease anxiety driving obsessive-compulsive cleaning, supporting therapy without confronting or enabling the behavior.
A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that:
- A. Multiple drug use is very uncommon
- B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms
- C. Alcohol and barbiturates used together are not dangerous because one is a stimulant and the other is a depressant
- D. Assessment and intervention are easier with multiple drug use because of the synergistic effect
Correct Answer: B
Rationale: Multiple drug use is common to enhance effects or relieve withdrawal symptoms, complicating assessment and intervention due to varied drug interactions.
The three universal spiritual needs include all of the following except:
- A. meaning and purpose.
- B. love and relatedness.
- C. forgiveness.
- D. God's permission.
Correct Answer: D
Rationale: Religious teachings help to present a meaningful philosophy and system of practices within a system of social controls having specific values, norms, and ethics. God is the center of many religions (major), but not all.