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A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate?
- A. Help the person use online video calls to provide interaction with others.
- B. Advise the person to accept the situation and use a companion.
- C. Ask the person to explain why the fear is so disabling.
- D. Teach the person to use positive self-talk techniques.
Correct Answer: D
Rationale: The correct answer is D, teaching the person to use positive self-talk techniques. This intervention is appropriate because it addresses the cognitive aspect of anxiety. By teaching the person to challenge negative thoughts and replace them with positive affirmations, they can gradually overcome their fear and build confidence in leaving the apartment. Online video calls (A) may provide temporary relief but do not address the root cause of the anxiety. Advising the person to use a companion (B) may enable avoidance of the problem rather than actively working on overcoming it. Asking the person to explain their fear (C) may not be helpful if they are already aware that it is irrational. Positive self-talk techniques empower the individual to change their mindset and behavior effectively.
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A client on a psychiatric unit is telling the nurse about anger toward the airline after losing an only child in a plane crash. In which situation is the nurse demonstrating active listening?
- A. Agreeing with the client.
- B. Repeating everything that the client says to clarify.
- C. Assuming a relaxed posture and leaning toward the client.
- D. Expressing sorrow and sadness regarding the client's loss.
Correct Answer: C
Rationale: The correct answer is C because assuming a relaxed posture and leaning toward the client demonstrates active listening by showing empathy and interest in what the client is saying. This nonverbal behavior encourages the client to continue expressing their feelings.
A: Agreeing with the client can shut down communication and invalidate the client's emotions.
B: Repeating everything the client says may come across as robotic and not conducive to building rapport.
D: Expressing sorrow and sadness, while empathetic, may shift the focus from the client to the nurse's emotions.
In summary, actively listening involves nonverbal cues that show understanding and support without interjecting personal opinions or emotions.
A psychiatric-mental health nurse is working with a patient who is being treated for depression. Which patient statement would indicate that her spirituality is intact?
- A. My church friends came to visit me this past Sunday afternoon.'
- B. Nothing will ever be the same again; my life is not worth living.'
- C. I know I am as well off as I can be under the circumstances.'
- D. I know God must be punishing me for all my sins.'
Correct Answer: C
Rationale: The correct answer is C because the patient's statement reflects a sense of acceptance and inner peace despite challenging circumstances, indicating a belief in a higher power or spirituality. This indicates that her spirituality is intact.
Choice A implies social support but does not necessarily indicate spirituality. Choice B expresses hopelessness and suicidal ideation, which are not indicative of intact spirituality. Choice D reflects feelings of guilt and punishment, which do not align with a sense of spiritual well-being.
The nurse is caring for a patient who has been under severe stress while caring for her elderly mother who is in the advanced stages of Alzheimer's disease. The nurse explains that the patient is adapting to the stress she is experiencing because of which of the following?
- A. Ability to survive in the midst of severe stress
- B. Acceptance of others'help in caring for her mother
- C. Success at being able to solve problems
- D. Capability in setting reasonable personal goals
Correct Answer: A
Rationale: Correct Answer: A: Ability to survive in the midst of severe stress
Rationale:
1. The patient is under severe stress due to caring for her mother with Alzheimer's disease.
2. Adaptation to stress involves the ability to survive and cope with challenging situations.
3. Surviving severe stress indicates the patient's resilience and ability to endure difficult circumstances.
4. This choice best reflects the patient's capacity to manage and withstand the stress she is facing.
Summary:
B: Acceptance of others' help in caring for her mother - This choice focuses on receiving help from others, which may not directly relate to the patient's ability to adapt to stress.
C: Success at being able to solve problems - While problem-solving skills are valuable, adaptation to stress goes beyond just solving problems.
D: Capability in setting reasonable personal goals - Setting goals is important but may not directly address the patient's adaptation to severe stress.
A client has made multiple visits to the clinic. The nurse suspects that the client may be experiencing complex somatic symptom disorder based on which of the following?
- A. Expressions of concern about psychological problems
- B. Indications that parents were always in 'good health'
- C. Reports of the same symptoms repeatedly
- D. Evidence of a need for social support from her friends
Correct Answer: C
Rationale: The correct answer is C: Reports of the same symptoms repeatedly. In complex somatic symptom disorder, individuals often report persistent physical symptoms with no clear medical explanation. By repeatedly reporting the same symptoms, the client demonstrates a key characteristic of this disorder. Choices A, B, and D do not directly align with the diagnostic criteria for complex somatic symptom disorder. Expressions of concern about psychological problems (A) could indicate other mental health conditions. Indications that parents were always in 'good health' (B) and evidence of a need for social support from friends (D) are not specific to complex somatic symptom disorder.
The nurse is assessing a child's cognitive ability to think logically. The nurse asks the child to count backward from 10 to 0, and the child complies. What cognitive stage is this child in?
- A. sensorimotor
- B. formal operational
- C. concrete operational
- D. preoperational
Correct Answer: C
Rationale: The child counting backward from 10 to 0 demonstrates conservation of numbers and reversibility, characteristics of the concrete operational stage. In this stage, children can engage in logical thought processes, manipulate information mentally, and understand conservation. This ability is typically developed around ages 7 to 11.
A: Sensorimotor stage focuses on sensory experiences and object permanence, typically occurring from birth to age 2.
B: Formal operational stage involves abstract thinking and hypothetical reasoning, usually from age 12 and beyond.
D: Preoperational stage includes egocentrism and lack of conservation, typical for children aged 2 to 7.
Therefore, the child counting backward is in the concrete operational stage due to their ability to think logically and understand conservation.