Nokea
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 despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate?
- A. Im confident you know whats best for you.
- B. This may not be the best time for you to make such an important decision.
- C. Your children will be terribly disappointed.
- D. Tell me why you want to make this change.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions and gently suggests caution in making a big decision during a vulnerable time. It shows empathy and encourages the client to reconsider the decision later. Choice A lacks exploration of client's feelings, Choice C introduces unnecessary guilt, and Choice D focuses on the change rather than the emotional state.
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.
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.
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.
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.