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A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?
- A. "It might help you feel better if you talk about it."
- B. "I'll just sit here with you for a few minutes then."
- C. "I understand. I've felt like that before, too."
- D. "Why are you feeling so down?"
Correct Answer: B
Rationale: The correct answer is B: "I'll just sit here with you for a few minutes then." This response demonstrates empathy and support without imposing solutions or pressuring the client to talk. It acknowledges the client's feelings and offers companionship, which can provide comfort and reassurance. Choice A may pressure the client to talk, which may not be what the client needs at the moment. Choice C shifts the focus to the nurse's own experiences, which may not be helpful for the client. Choice D may come across as confrontational or dismissive of the client's emotions. Therefore, choice B is the most appropriate response in this situation.
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A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
- A. "I plan to sit on a park bench for a few minutes each day."
- B. "I can try participating in group therapy every week."
- C. "I will join a book club in my neighborhood."
- D. "I should avoid entering elevators and other closed spaces."
Correct Answer: A
Rationale: The correct answer is A: "I plan to sit on a park bench for a few minutes each day." This statement indicates the client's understanding of gradual exposure therapy, a common treatment for agoraphobia. Exposure to feared situations in a controlled manner helps desensitize the client to their anxiety triggers. Sitting on a park bench signifies a small step towards facing the fear of open spaces. Choices B, C, and D do not directly address the core issue of agoraphobia or the specific treatment approach. Group therapy and joining a book club may be beneficial but do not target the fear of open spaces. Avoiding elevators and closed spaces is a safety behavior that reinforces the fear and hinders recovery.
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification?
- A. "I have heard that abusers try to keep their partner isolated from others."
- B. "I know that abusers lack social supports and social skills."
- C. "I know that men who are abusers gain power through intimidation."
- D. "I have heard that abusers think of themselves as important and have high self-esteem."
Correct Answer: D
Rationale: Answer D indicates a need for clarification because it presents a misconception about abusers. Abusers typically have low self-esteem and use power and control to compensate. This statement falsely suggests that abusers have high self-esteem and view themselves as important. This misunderstanding could lead to overlooking warning signs and risks associated with domestic violence. It's crucial for healthcare professionals to recognize the true dynamics of abusive relationships to provide appropriate support and interventions. Other choices (A, B, C) align with common knowledge about domestic violence, highlighting the tactics and behaviors typically associated with abusers.
A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
- A. "I'm glad you called, and I want to send an ambulance to help you."
- B. "You must have been feeling pretty depressed to do that."
- C. "Do you know how many pills were in the bottle?"
- D. "Were you trying to kill yourself by taking an overdose?"
Correct Answer: A
Rationale: The correct response is A: "I'm glad you called, and I want to send an ambulance to help you." This answer demonstrates immediate concern for the client's well-being and prioritizes getting them the necessary medical help. It acknowledges the seriousness of the situation and the potential danger of taking an entire bottle of medication. Sending an ambulance ensures that the client receives prompt medical attention, which is crucial in cases of overdose.
Incorrect responses:
B: "You must have been feeling pretty depressed to do that." - This response focuses on the client's emotional state rather than addressing the immediate need for medical assistance.
C: "Do you know how many pills were in the bottle?" - This question does not prioritize the urgency of the situation and does not address the immediate need for medical help.
D: "Were you trying to kill yourself by taking an overdose?" - This response may come off as accusatory and could potentially escalate the situation. It is important to prioritize the client's safety and well-being
A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?
- A. "The legal requirement for client confidentiality ceases if the client is deceased."
- B. "Staff members are required to divulge information to attorneys if they call for information."
- C. "Health care workers are not required to answer a court's requests for information about a client's disclosure."
- D. "Providers are required to warn individuals if the client threatens harm."
Correct Answer: D
Rationale: The correct answer is D because it refers to the duty to warn, which is a legal exception to client confidentiality. When a client poses a serious and imminent threat of harm to others, healthcare providers have a duty to warn those at risk. This exception prioritizes public safety over confidentiality.
Explanation of why other choices are incorrect:
A: Incorrect. Confidentiality typically extends even after a client's death to protect their privacy rights and maintain trust in healthcare providers.
B: Incorrect. Disclosing information to attorneys without client consent violates confidentiality unless required by law or court order.
C: Incorrect. Healthcare workers are generally required to comply with court requests for information unless protected by a legal privilege.
E, F, G: Not provided.
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
- A. "I check any room I enter because the enemy is still after me and could be hiding anywhere."
- B. "I killed four enemy soldiers with my bare hands and saved my entire battalion."
- C. "My child was born with a birth defect due to an exposure I had overseas."
- D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Correct Answer: D
Rationale: The correct answer is D because the statement indicates the client is experiencing intrusive memories and nightmares, which are common symptoms of PTSD. This suggests the client is reliving the traumatic event. Choice A suggests hypervigilance, which can be a symptom of PTSD but is not as specific as intrusive memories. Choice B indicates possible grandiosity or exaggerated sense of self-importance. Choice C suggests guilt related to a different issue. Summarily, choices A, B, and C do not directly align with the hallmark symptoms of PTSD like choice D does.