Nokea
An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?
- A. Encourage exploration of sexual abuse
- B. Encourage guided imagery
- C. Establish trust and rapport
- D. Administer antianxiety medications
Correct Answer: C
Rationale: The correct answer is C: Establish trust and rapport. This is the priority because building a therapeutic relationship is essential for effective treatment of DID. Trust and rapport are foundational for the client to feel safe and supported in exploring and processing traumatic experiences. Encouraging exploration of sexual abuse (Option A) may be overwhelming and retraumatizing without a solid therapeutic alliance. Guided imagery (Option B) might not be appropriate at this stage as the client needs to establish trust first. Administering antianxiety medications (Option D) alone does not address the root cause or provide the necessary support for the client's complex trauma history.
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When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
- A. Hiding liquor bottles in a closet
- B. Yelling at their son for slouching in his chair
- C. Burning dinner on purpose
- D. Saying to the spouse, I dont drink too much!
Correct Answer: D
Rationale: The correct answer is D because the client is using denial as a defense mechanism to cope with the stress of being confronted about her alcohol abuse. By saying "I don't drink too much," she is refusing to acknowledge the reality of her excessive alcohol consumption. This denial allows her to avoid facing the uncomfortable truth and the need for change.
A: Hiding liquor bottles in a closet is an example of a defense mechanism called displacement, not denial.
B: Yelling at their son for slouching in his chair is an example of a defense mechanism called projection, not denial.
C: Burning dinner on purpose is an example of a defense mechanism called passive-aggression, not denial.
During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the mans loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurses action?
- A. The nurses action should be evaluated as unacceptable due to breech of cultural norms.
- B. The nurses action should be evaluated as empathetic, encouraging expression of feelings.
- C. The nurses action should be evaluated as the technique of offering self.
- D. The nurses action should be evaluated as inappropriate due to poor timing.
Correct Answer: A
Rationale: The correct answer is A because the nurse's action of hugging the man from Syria who just lost his son in a car accident breaches cultural norms. In many Middle Eastern cultures, physical touch, especially between unrelated individuals of the opposite sex, is considered inappropriate and can be seen as disrespectful. This can cause discomfort and may even offend the individual. In this scenario, the nurse should respect the man's cultural background and find alternative ways to show empathy and support, such as verbal expressions of sympathy or offering a comforting presence.
Choice B is incorrect because while the nurse may have intended to show empathy, the method of hugging was culturally inappropriate. Choice C is incorrect as offering self typically involves sharing personal experiences to build rapport, not physical touch. Choice D is also incorrect as the issue lies more with cultural norms rather than poor timing.
During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development?
- A. Its hard for me to tell my story when Im not sure about the reactions of others.
- B. I think Joes Antabuse suggestion is a good one and might work for me.
- C. My situation is very complex, and I need professional, not peer, advice.
- D. I am really upset that you expect me to solve my own problems.
Correct Answer: B
Rationale: The correct answer is B because it shows the client actively engaging in problem-solving and considering specific strategies, indicating progress to the working phase. Choice A reflects the initial phase where trust and sharing are still developing. Choice C suggests a dependency on professional advice, not group collaboration. Choice D demonstrates resistance and a lack of ownership over personal growth, indicating an earlier phase of group development.
What is the purpose of a nurse providing appropriate feedback?
- A. To give the client good advice
- B. To advise the client on appropriate behaviors
- C. To evaluate the clients behavior
- D. To give the client critical information
Correct Answer: C
Rationale: The purpose of a nurse providing appropriate feedback is to evaluate the client's behavior. This involves assessing the client's actions, understanding their needs, and determining the effectiveness of the care provided. Feedback helps in identifying areas for improvement and guiding the client towards better health outcomes. Choice A is incorrect as feedback is not solely about giving advice. Choice B is incorrect as feedback is not limited to advising on behaviors. Choice D is incorrect as feedback goes beyond just providing critical information to include a holistic evaluation of the client's overall behavior and progress.
From an interpersonal theory perspective, which intervention would a nurse use to assist a client diagnosed with major depressive disorder?
- A. Offer family therapy sessions
- B. Discuss childhood events
- C. Teach alternate coping skills
- D. Encourage discussion of feelings
Correct Answer: A
Rationale: The correct answer is A because family therapy sessions can help address underlying family dynamics contributing to the client's depression. This intervention aligns with interpersonal theory, which focuses on improving relationships and communication within the client's social network. Family therapy can enhance support systems and promote healthier interactions.
Option B is incorrect as discussing childhood events may not directly address current interpersonal difficulties. Option C, teaching coping skills, is helpful but may not target the interpersonal issues specific to major depressive disorder. Option D, encouraging discussion of feelings, is important but may not address the broader interpersonal dynamics impacting the client's condition.