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At what point should the nurse determine that a client is at risk for developing a mental disorder?
- A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
- B. When maladaptive responses to stress are coupled with interference in daily functioning
- C. When the client communicates significant distress
- D. When the client uses defense mechanisms as ego protection
Correct Answer: B
Rationale: The correct answer is B. When maladaptive responses to stress are coupled with interference in daily functioning, the nurse should determine that a client is at risk for developing a mental disorder. This is because maladaptive responses to stress, such as excessive worry or avoidance behaviors, can be early signs of mental health issues. When these responses start impacting daily functioning, such as affecting work or relationships, it indicates a higher level of risk for a mental disorder. Choices A, C, and D are incorrect because they do not specifically address the combination of maladaptive responses to stress and interference in daily functioning, which are key indicators of potential mental health issues.
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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.
In the role of milieu manager, which activity should the nurse prioritize?
- A. Setting the schedule for the daily unit activities
- B. Evaluating clients for medication effectiveness
- C. Conducting therapeutic group sessions
- D. Searching newly admitted clients for hazardous objects
Correct Answer: D
Rationale: The correct answer is D, searching newly admitted clients for hazardous objects. As a milieu manager, ensuring the safety of clients is a top priority. Searching for hazardous objects upon admission is crucial to prevent harm. Setting schedules (A) can be important but not as urgent as ensuring safety. Evaluating medication effectiveness (B) is important but not the primary role of a milieu manager. Conducting group sessions (C) is valuable for therapy but ensuring physical safety takes precedence.
According to Eriksons developmental theory, when planning care for a 47-year-old client, which developmental task should a nurse identify as appropriate for this client?
- A. To achieve a sense of self-confidence and recognition from others
- B. To reflect back on life events to derive pleasure and meaning
- C. To achieve established life goals and consider the welfare of future generations
Correct Answer: B
Rationale: In Erikson's theory, the developmental task for a 47-year-old client aligns with the stage of Generativity vs. Stagnation. Choice B, reflecting on life events for pleasure and meaning, corresponds to this stage where individuals assess their accomplishments and seek fulfillment. This phase involves contributing to society and future generations. Choice A pertains to the earlier stage of Identity vs. Role Confusion in adolescence. Choice C aligns with the later stage of Integrity vs. Despair in older adulthood. Choice D is incomplete. Therefore, the correct answer is B as it best fits the age and developmental stage of the client in question.
Which client statement may indicate a transference reaction?
- A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life.
- B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor.
- C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself.
- D. My mother is the source of my problems. She has always told me what to do and what to say.
Correct Answer: A
Rationale: Step 1: The client's statement "I need a real nurse" suggests a desire for a particular type of nurse, implying a transfer of feelings from a significant person onto the nurse.
Step 2: The client mentioning the nurse's age and relationship dynamics ("young enough to be my daughter") indicates projection of unresolved emotions onto the nurse.
Step 3: The client's reluctance to share personal information and discomfort with the nurse's perceived identity further supports the presence of transference reactions.
Summary: Option A is correct as it demonstrates transference by projecting emotions onto the nurse based on age and personal dynamics. Other choices lack clear indications of transference and focus on different issues like entitlement, social interaction difficulties, and blaming family members.
When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate?
- A. Decreased resistance to disease
- B. Increased libido
- C. Decreased blood pressure
- D. Increased inflammatory response
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to disease. Prolonged stress can weaken the immune system, making individuals more susceptible to illnesses. Chronic stress suppresses immune functions, leading to decreased resistance to diseases. The other choices are incorrect because increased libido (B) and decreased blood pressure (C) are not typical physiological effects of sustained stress. While stress can lead to increased inflammatory response (D), the primary concern with chronic stress is its negative impact on the immune system, making choice A the most appropriate answer in this context.