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During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.
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A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: Perhaps this was the best thing to happen. Maybe Ill look into pursuing an art degree. How should the nurse characterize the clients appraisal of the job loss stressor?
- A. Irrelevant
- B. Harm/loss
- C. Threatening
- D. Challenging
Correct Answer: D
Rationale: The correct answer is D: Challenging. The client's statement indicates a positive reframing of the job loss as an opportunity for personal growth. This suggests that the client views the situation as a challenge to adapt and pursue a new path. This perspective aligns with the concept of stress as a potential source of growth and development, known as the challenge appraisal.
Summary:
A: Irrelevant - The client's statement demonstrates relevance to his future plans, making this choice incorrect.
B: Harm/loss - The client's positive outlook does not reflect a perception of harm or loss, making this choice incorrect.
C: Threatening - The client's statement does not convey a perception of threat, making this choice incorrect.
A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation?
- A. Everyone diagnosed with OCD needs to control their ritualistic behaviors.
- B. It is important for you to discontinue these ritualistic behaviors.
- C. Why are you asking for help if you wont participate in unit therapy?
- D. Lets figure out a way for you to attend unit activities and still wash your hands.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the client's need to wash their hands due to OCD while also addressing the issue of missing unit activities. By suggesting finding a way for the client to attend activities while still accommodating their need to wash hands, it promotes a collaborative approach and respects the client's autonomy. Option A is incorrect as not everyone with OCD can completely control their behaviors. Option B is too directive and may increase resistance. Option C is confrontational and may discourage the client from seeking help.
A nurse understands that the abnormal secretion of growth hormone may play a role in which illness?
- A. Schizophrenia
- B. Anorexia nervosa
- C. Alzheimers disease
Correct Answer: B
Rationale: The correct answer is B: Anorexia nervosa. Growth hormone abnormalities can contribute to the development of anorexia nervosa by affecting metabolism and body composition. Increased levels of growth hormone can lead to muscle wasting and weight loss, which are common symptoms of anorexia nervosa. In contrast, schizophrenia is primarily associated with neurotransmitter imbalances, Alzheimer's disease is linked to neurodegeneration, and diabetes is often related to insulin abnormalities.
An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
- A. The employee assertively confronts the boss
- B. The employee leaves the staff meeting to work out in the gym
- C. The employee criticizes a coworker
- D. The employee takes the boss out to lunch
Correct Answer: C
Rationale: Displacement is a defense mechanism where emotions are redirected from the original source to a substitute target. In this case, the employee is likely to displace their anger from the boss onto a coworker by criticizing them. This behavior allows the employee to express their feelings indirectly.
A: Assertively confronting the boss does not align with displacement as it involves direct confrontation.
B: Leaving the meeting to work out in the gym is a form of avoidance and does not involve displacing emotions onto another target.
D: Taking the boss out to lunch is more of a conciliatory gesture and does not involve displacing negative emotions onto someone else.
Which rationale by a nursing instructor best explains why it is challenging to globally classify the Asian American culture?
- A. Extremes of emotional expression prevent accurate assessment of this culture.
- B. Suspicion of Western civilization has resulted in minimal cultural research.
- C. The small size of this subpopulation makes research virtually impossible.
- D. The Asian American culture includes individuals from many different countries.
Correct Answer: D
Rationale: The correct answer is D because the Asian American culture is not monolithic but comprises individuals from diverse Asian countries with unique customs, languages, and traditions. This diversity makes it challenging to globally classify the culture as a whole. Option A is incorrect as emotional expression varies within Asian American communities. Option B is incorrect as there has been cultural research on Asian Americans. Option C is incorrect as the size of the population does not hinder research efforts.