Nokea
A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
- A. An adult client following a suicide attempt
- B. A school-age client who attempts to repeatedly bite staff
- C. An adolescent client who throws objects at other clients
- D. An older adult client who is manic and crying due to overstimulation
Correct Answer: A
Rationale: Correct Answer: A. Seclusion is contraindicated for an adult client following a suicide attempt. This client may already be in a vulnerable state and seclusion could exacerbate feelings of isolation and hopelessness, potentially leading to further harm. It is important to maintain close observation and provide supportive interventions.
Incorrect Choices:
B: Seclusion may be considered for a school-age client who attempts to bite staff to ensure the safety of both the client and staff.
C: Seclusion may be necessary for an adolescent client who poses a risk to others by throwing objects to prevent harm to self and others.
D: Seclusion may be used for an older adult client who is manic and overstimulated to provide a calm and safe environment for de-escalation.
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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.
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has placed locks at the top of the doors leading to the outside.
- B. The partner has hired a house cleaner.
- C. The partner has lost 20 lb in the past 2 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 20 lb in the past 2 months indicates caregiver role strain. Significant weight loss can be a sign of stress, neglecting self-care, and being overwhelmed by caregiving responsibilities. This observation suggests that the partner may not be prioritizing their own well-being while caring for the client with Alzheimer's disease.
Choice A is incorrect because placing locks at the top of doors is a safety measure commonly taken to prevent the client with Alzheimer's disease from wandering outside unsupervised. Choice B is incorrect as hiring a house cleaner can be a practical solution to manage household tasks and does not necessarily indicate caregiver role strain. Choice D is incorrect because redirecting the client when frustrated is a positive caregiving technique to manage challenging behaviors.
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how alcohol use affects the client's psychosocial behaviors?
- A. "Has alcohol use affected your performance at work?"
- B. "Have you received prior treatment for substance use disorder?"
- C. "Do you receive treatment for any mental health disorders?"
- D. "At what age did you begin drinking alcohol?"
Correct Answer: A
Rationale: The correct answer is A. By asking if alcohol use has affected the client's performance at work, the nurse can assess the impact of alcohol on the client's psychosocial behaviors, such as work productivity and relationships with colleagues. This question directly addresses the behavioral consequences of alcohol use.
Explanation for incorrect choices:
B: Asking about prior treatment for substance use disorder focuses on the past rather than the current impact on psychosocial behaviors.
C: Inquiring about treatment for mental health disorders is relevant but does not specifically address the psychosocial effects of alcohol use.
D: Asking at what age the client began drinking alcohol provides historical information but does not assess current psychosocial behaviors.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.
A nurse is assessing a client who has post-traumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
- A. Sleeping 12 hours or more each day
- B. Increasing sense of attachment to others
- C. Constricted willingness to talk about the event
- D. Increasing feelings of anger
Correct Answer: C
Rationale: Avoidance of discussing the traumatic event is a key symptom of PTSD.