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Based on assessment data, the nurse formulates the nursing diagnosis for a patient as sleep pattern disturbance. After teaching the patient how to relax before bedtime, the nurse determines that the teaching was effective by which outcome?
- A. Discusses feelings about not being able to fall asleep
- B. Reports feeling rested on awakening in the morning within 3 days
- C. Requests sleeping medication each night before bedtime
- D. Is able to sleep for short intervals throughout the night
Correct Answer: B
Rationale: The correct answer is B because feeling rested upon awakening indicates improved sleep quality, reflecting effective teaching on relaxation techniques. Choice A does not directly measure the effectiveness of the teaching intervention. Choice C indicates reliance on medication rather than improved sleep hygiene. Choice D, sleeping for short intervals, does not necessarily signify improved sleep quality.
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What behavior is a client with a diagnosis of antisocial personality disorder demonstrating when they engage in binge drinking?
- A. a defiant personality
- B. emotional regulation
- C. maladaptive behavior
- D. self-determination
Correct Answer: C
Rationale: The correct answer is C: maladaptive behavior. Clients with antisocial personality disorder often engage in maladaptive behaviors, such as binge drinking, to cope with their emotions and impulsivity. Binge drinking is a harmful coping mechanism that can lead to negative consequences, reflecting maladaptive behavior. Choice A (defiant personality) is incorrect as it does not directly relate to the behavior of binge drinking. Emotional regulation (Choice B) is also incorrect as individuals with antisocial personality disorder typically struggle with regulating their emotions, leading to impulsive behaviors like binge drinking. Self-determination (Choice D) is not the most appropriate answer as it does not directly address the maladaptive nature of binge drinking in individuals with antisocial personality disorder.
While caring for a family, the nurse determines that first-order changes have occurred with which of the following?
- A. The children are all in school, and the parent returns to work.
- B. The daughter leaves home to attend college.
- C. The son marries his long-time sweetheart and moves into his own home.
- D. The grandmother who has been living in the household dies.
Correct Answer: A
Rationale: The correct answer is A because first-order changes refer to small, incremental adjustments within the system. In this scenario, the parent returning to work while the children are all in school signifies a gradual shift in the family dynamic. The other choices involve significant and more disruptive changes like a daughter leaving for college, a son getting married and moving out, and the death of a family member, which are considered second-order changes that lead to more substantial shifts in the family system.
A client diagnosed with complex somatic symptom disorder and depression is prescribed medication therapy to treat both the pain and the symptoms of depression. When teaching the client about the medication, which of the following would the nurse emphasize?
- A. Need for signing a no-suicide contract
- B. Avoidance of foods that contain aged cheese
- C. Use of sunscreen when exposed to bright sunlight
- D. Limiting of the amount of water ingested
Correct Answer: B
Rationale: The correct answer is B: Avoidance of foods that contain aged cheese. Aged cheese contains tyramine, which can interact with certain medications used to treat depression, such as MAOIs. This interaction can lead to a dangerous increase in blood pressure known as a hypertensive crisis. Therefore, it is crucial for the client to avoid foods high in tyramine, such as aged cheese, to prevent this potentially life-threatening reaction. Signing a no-suicide contract (choice A) is important but not directly related to medication teaching. Using sunscreen (choice C) and limiting water intake (choice D) are not relevant considerations for this medication regimen.
A nurse who has worked with a client diagnosed with generalized anxiety disorder (GAD) when he was an inpatient on the psychiatric unit sees the client in the waiting room of the outpatient psychiatric clinic. The client motions to the nurse to come over so he can tell the nurse how things have been going since he was discharged. While talking with the client, the nurse determines that the client's therapy has been effective when the client states which of the following?
- A. I am still experiencing quite a bit of stress at home and at work; things are different at home than they were in the hospital.
- B. When my mother-in-law comes over now, I go out to my workshop and work on one of my projects.
- C. I'm still drinking coffee; I can't quit after drinking it all these years.
- D. I've learned having a beer after I get home from work helps me relax.
Correct Answer: B
Rationale: The correct answer is B because the client's behavior of going to the workshop to work on projects when his mother-in-law visits indicates a healthy coping mechanism to manage stress. This shows that the therapy has been effective in helping the client find a constructive way to deal with his anxiety triggers. Choice A indicates ongoing stress, which suggests therapy may not be effective. Choice C shows a habit that has not changed, indicating little progress. Choice D suggests the use of alcohol as a coping mechanism, which is not a healthy or sustainable way to manage anxiety.
Which technique is most applicable to aversion therapy?
- A. Punishment
- B. Desensitization
- C. Role modeling
- D. Positive reinforcement
Correct Answer: A
Rationale: Aversion therapy aims to reduce unwanted behaviors by associating them with negative consequences. Punishment, option A, is the most applicable technique as it involves applying an unpleasant stimulus to decrease the likelihood of a behavior occurring again. Desensitization (B) and positive reinforcement (D) aim to increase desired behaviors, which is not the goal of aversion therapy. Role modeling (C) involves observing and imitating others' behaviors, which is unrelated to aversion therapy's principles.