Nokea
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?
- A. "It will help you feel better if you talk about it."
- B. "I'll come back when you feel like talking."
- C. "I'll stay with you a few minutes."
- D. "Coming with me to the day room will take your mind off your troubles."
Correct Answer: C
Rationale: Staying with the client provides support without pressuring them to talk.
You may also like to solve these questions
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
- A. Inform the client of consequences.
- B. Speak slowly in a low, calm voice.
- C. Forbid the client from speaking in an abusive manner.
- D. Remain a distance of 1 ft away from the client.
Correct Answer: B
Rationale: Speaking calmly helps de-escalate aggression.
A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?
- A. Dialectical behavior therapy
- B. Behavioral contract
- C. Milieu therapy
- D. Safety plan
Correct Answer: D
Rationale: The correct answer is D: Safety plan. For a client with borderline personality disorder, a safety plan is crucial to prevent self-harm or suicidal behaviors. This intervention helps the client identify triggers, coping strategies, support resources, and steps to take in a crisis. A: Dialectical behavior therapy is a comprehensive treatment, not just a discharge plan. B: Behavioral contract may not address the immediate safety concerns. C: Milieu therapy focuses on the therapeutic environment, not individual discharge planning.
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following actions should be included in the plan of care?
- A. Allow manipulation so as to not raise the client’s anxiety.
- B. Avoid discussing past behaviors with the client.
- C. Bargain with the client to discourage manipulative behavior.
- D. Set clear and consistent limits on manipulative behaviors.
Correct Answer: D
Rationale: The correct answer is D: Set clear and consistent limits on manipulative behaviors. By setting clear boundaries, the nurse establishes a structured environment that promotes accountability and helps the client understand appropriate behavior. This method reinforces boundaries and helps the client learn to interact in a healthier way.
Explanation for other choices:
A: Allowing manipulation does not address the underlying issue and may enable further manipulative behavior.
B: Avoiding discussing past behaviors hinders the therapeutic process and may prevent understanding and resolution of manipulative tendencies.
C: Bargaining with the client only reinforces manipulative behavior and does not address the root cause.
In summary, setting clear and consistent limits is the most effective approach in managing manipulative behavior.
A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
Correct Answer: A
Rationale: Persecutory delusions involve irrational beliefs that one is being targeted or harmed by external forces.
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. "My parents treat me like a baby sometimes."
- B. "I haven't gotten my period yet, and all my friends have theirs."
- C. "None of the kids at this school like me, and I don't like them either."
- D. "There's a big pimple on my face, and I worry that everyone will notice it."
Correct Answer: C
Rationale: The correct answer is C. The nurse's priority should be to address the adolescent's statement about not liking any kids at school and feeling disliked by others. This suggests potential social isolation, which can impact mental health and well-being. Addressing social relationships is crucial at this age for emotional development. Choices A, B, and D are important but not urgent concerns. Choice A relates to family dynamics, B to physical development, and D to self-image; while these are valid issues, they do not have immediate implications for the adolescent's well-being like the social isolation expressed in choice C.