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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.
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Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
A client is trying to explore and solve a problem. Which nursing statement would be an example of verbalizing the implied?
- A. You seem to be motivated to change your behavior.
- B. How will these changes affect your family relationships?
- C. Why dont you make a list of the behaviors you need to change.
- D. The team recommends that you make only one behavioral change at a time.
Correct Answer: A
Rationale: Step 1: A is correct as it reflects active listening and shows empathy towards the client.
Step 2: By stating "You seem to be motivated to change your behavior," the nurse acknowledges the client's feelings and encourages further exploration.
Step 3: This statement helps the client feel understood and supported in their journey towards change.
Summary:
B: Focuses on family relationships, not the client's motivation.
C: Suggests a directive approach rather than exploring the client's feelings.
D: Imposes a specific recommendation without considering the client's readiness or motivation.
A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction?
- A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing.
- B. The Nurse Practice Act lists education requirements for licensure and reciprocity.
- C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs).
- D. The Nurse Practice Act lists the general authority and powers of the state board of nursing.
Correct Answer: B
Rationale: The correct answer is B because education requirements for licensure and reciprocity are typically not included in the Nurse Practice Act. The Act primarily focuses on defining the scope of practice, authority of the state board, regulations, and standards for nursing practice. Education requirements are usually outlined in separate regulations or guidelines by the state board of nursing or accrediting bodies. Therefore, if a student statement mentions education requirements as part of the Nurse Practice Act, it indicates a need for further instruction as it is not accurate.
A: This statement is correct as the Nurse Practice Act often includes definitions of important terms to provide clarity and understanding.
C: This statement is correct as the Act does describe the scope of practice for registered nurses to ensure safe and competent care.
D: This statement is correct as the Act typically outlines the general authority and powers of the state board of nursing to regulate and oversee nursing practice.
A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse should associate this response with which neurotransmitter?
- A. Dopamine
- B. Serotonin
- C. Norepinephrine
Correct Answer: C
Rationale: The correct answer is C, Norepinephrine. During the fight-or-flight response, the sympathetic nervous system is activated, leading to the release of norepinephrine. Norepinephrine increases heart rate, blood pressure, and alertness, preparing the body to either fight or flee from a perceived threat. Dopamine (A) is more related to reward and pleasure. Serotonin (B) is involved in regulating mood and emotions. Cortisol (D) is a stress hormone, not a neurotransmitter involved in the fight-or-flight response.
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, You are incompetent! Which is the nurses best response?
- A. Do you believe that I was the cause of your blood test being canceled?
- B. I see that you are upset, but I feel uncomfortable when you swear at me.
- C. Have you ever thought about ways to express anger appropriately?
- D. Ill give you some space. Let me know if you need anything.
Correct Answer: B
Rationale: The correct answer is B: "I see that you are upset, but I feel uncomfortable when you swear at me." This response acknowledges the client's emotion while setting a boundary against inappropriate behavior. It demonstrates empathy towards the client's feelings without condoning the swearing. It also communicates the nurse's discomfort with the behavior, which can help in de-escalating the situation.
A: Choice A deflects responsibility and may come off as defensive, not addressing the client's emotions directly.
C: Choice C shifts the focus away from the client's immediate distress and may not be well-received in the heat of the moment.
D: Choice D, while giving space, doesn't address the behavior directly and may not effectively address the client's emotions or the impact of their actions on the nurse.