Nokea
An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
- A. "I think I was a lonely child because I could not tell anyone about my abuse."?
- B. "I am now aware of how deep-seated my anger is. Before, I did not realize I was angry."?
- C. "The program has given me the courage to tell my mother how I felt about her role in my hurt."?
- D. "There are so many people just like me, who are just normal people that had bad things happen to them."?
Correct Answer: B
Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.
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A client with schizophrenia says, 'I'm away for the day ... but don't think we should play "? or do we have feet of clay?' Which alteration in the client's speech does the nurse document?
- A. Neologism
- B. Word salad
- C. Clang association
- D. Associative looseness
Correct Answer: D
Rationale: The correct answer is 'Associative looseness.' In the provided speech, the client shows associative looseness by making loose connections between phrases without a clear logical link. Clang association involves rhyming words without regard for their meaning. Neologism refers to made-up words with specific meaning to the client, and word salad is a jumble of words that lack coherence either to the listener or the client. Understanding these speech patterns associated with schizophrenia is crucial in identifying the specific alteration in speech displayed by the client in this scenario.
The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this, the nurse should:
- A. tell the client to stop using the defense mechanism of denial.
- B. positively reinforce each expression of feelings.
- C. instruct the client to express feelings.
- D. challenge the client each time denial is used.
Correct Answer: B
Rationale: In the scenario provided, the nurse aims to reduce the client's use of denial and encourage the expression of feelings. Positive reinforcement for each expression of feelings is an effective approach to achieve this goal. By positively reinforcing the client's expression of feelings, the nurse encourages the desired behavior, making it more likely for the client to continue sharing their emotions. This approach creates a supportive and accepting environment for the client. In contrast, telling the client to stop using denial (Choice A) may create resistance and inhibit communication by putting pressure on the client. Instructing the client to express feelings (Choice C) is less effective as it lacks the element of reinforcement that is essential for behavior modification. Challenging the client each time denial is used (Choice D) may lead to defensiveness and hinder the therapeutic relationship, making it a less favorable option.
How should Lasix be administered to prevent hypotension?
- A. By administering it over 1-2 minutes
- B. By hanging it IV piggyback
- C. With normal saline only
- D. By administering it through a venous access device
Correct Answer: A
Rationale: Lasix should be administered over 1-2 minutes at approximately 1mL per minute to prevent hypotension. This slow administration helps to reduce the risk of adverse effects such as sudden drops in blood pressure. Choice B is incorrect because Lasix does not need to be hung IV piggyback, choice C is incorrect as Lasix administration does not require it to be mixed with normal saline only, and choice D is incorrect as Lasix does not have to be specifically administered through a venous access device (VAD) to prevent hypotension.
After experiencing a traumatic event like losing a child due to poisoning, a client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The correct answer is C: sociocultural indicator. In this situation, the client's reluctance to make new friends after experiencing a traumatic event like losing a child due to poisoning reflects a change in their social behavior, which is influenced by sociocultural factors. This response indicates how stress can impact a person's relationships and social interactions. Choice A, emotional indicator, is incorrect because the client's statement is more related to social interactions than emotional expression. Choice B, spiritual indicator, is incorrect as the given scenario does not directly involve spiritual beliefs or practices. Choice D, intellectual indicator, is also incorrect as the client's statement does not reflect cognitive or intellectual changes but rather social aspects affected by the stressful event.
A client sitting alone and talking to voices is observed by a nurse. When asked, the client reports he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: C
Rationale: When a client reports talking to voices, it can indicate the presence of hallucinations. Asking the client to describe what is happening is a crucial step as it helps the nurse understand the nature of the hallucinations and provides reassurance to the client. Touching the client without consent is inappropriate and can be distressing. Leaving the client alone may not address the underlying issue, and telling the client there are no voices denies their experience and can lead to mistrust.