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A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?
- A. "Yes, I understand that you feel better wearing your bracelet."
- B. "Why do you think the copper helps with your arthritis?"
- C. "Believing objects have powers to make you feel better has no scientific basis."
- D. "I think you should rely more on your medication therapy than on your bracelet."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should acknowledge and validate the client's feelings and beliefs regarding the copper bracelet without dismissing them. By responding with empathy and understanding, the nurse can establish a trusting relationship with the client. This approach can lead to open communication and collaboration in the client's care. It is important to respect the client's perspective and provide support rather than judgment.
Incorrect Choices:
B: Asking the client why she thinks the copper helps may come off as dismissive or confrontational, potentially alienating the client.
C: Dismissing the client's beliefs outright can damage the nurse-client relationship and hinder effective communication.
D: Suggesting the client rely more on medication than the bracelet may be perceived as disregarding the client's preferences and autonomy in managing her condition.
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A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
- A. Praise the client for looking at herself in a mirror.
- B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
- C. Reprimand the client about the potential damage that has occurred due to overexercising.
- D. Restrict the client from being weighed.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Asking the client to agree to talk to a nurse whenever she feels the urge to exercise is the most appropriate action. This approach promotes open communication and allows for timely intervention to address the client's excessive exercise behavior. It also demonstrates empathy and support, which are crucial in managing anorexia nervosa. By creating a safe space for the client to express her feelings, the nurse can help prevent further harm caused by overexercising.
Summary of other choices:
A: Praising the client for looking at herself in a mirror may reinforce distorted body image perceptions and unhealthy behaviors.
C: Reprimanding the client could lead to feelings of guilt and shame, exacerbating the client's condition.
D: Restricting the client from being weighed may not address the underlying issue of overexercising and can contribute to feelings of lack of control.
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
- A. Prepare for gastric lavage due to an extremely elevated lithium level.
- B. Administer the morning dose of lithium.
- C. Check the client's medication record to assess whether the client has been refusing her lithium.
- D. Hold the medication and assess for early manifestations of toxicity.
Correct Answer: B
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L).
A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
- A. "So, it seems that you feel responsible for what happened to your mother."
- B. "Your mother will be fine. You shouldn't worry so much."
- C. "Why do you blame yourself? You could not have prevented the stroke."
- D. "You are not responsible for your mother's stroke, but many people in your situation feel this way."
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A is the correct response because it acknowledges the son's feelings without dismissing or invalidating them. It shows empathy and understanding towards his guilt, opening up a conversation for further exploration of his emotions. It reflects active listening and validates his concerns.
Summary of Incorrect Choices:
B: This response minimizes the son's feelings and does not address his sense of guilt, which can further exacerbate his emotional distress.
C: While this response provides reassurance, it does not address the son's feelings of guilt and may come off as dismissive.
D: This response acknowledges the son's feelings but does not directly validate his sense of responsibility, missing an opportunity for therapeutic communication.
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
- A. Establish a client relationship.
- B. Explain to the client that the behavior was unacceptable.
- C. Explore the truth of the client’s statements.
- D. Set behavioral limits for the client.
Correct Answer: D
Rationale: Setting behavioral limits helps establish expectations for the client’s conduct in the unit.
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.