Nokea
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.
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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 client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
- A. History of alcohol dependence
- B. History of personality disorder
- C. History of schizophrenia
- D. History of hypertension
Correct Answer: A
Rationale: The correct answer is A: History of alcohol dependence. Alprazolam is a benzodiazepine and can be addictive, especially for individuals with a history of substance abuse like alcohol dependence. This client population is at higher risk for misuse, addiction, and overdose. It is important for the nurse to question this order to avoid potential harm. Choices B, C, and D are incorrect as they do not directly impact the safety or efficacy of alprazolam for acute anxiety.
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.
In the situation presented, which nursing intervention constitutes false imprisonment?
- A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained.
- B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion.
- C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return.
- D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.
Correct Answer: A
Rationale: The correct answer is A because false imprisonment occurs when a person is unlawfully restrained. In this scenario, the client is restrained without a physician's order, which is considered unlawful. Seeking a physician's order after the client is already restrained does not justify the action.
Choice B is incorrect because seclusion is a valid nursing intervention for managing disruptive behavior, as long as it is done in a safe and ethical manner.
Choice C is incorrect because the nurse's actions of running after the client and convincing them to return do not constitute false imprisonment.
Choice D is incorrect because preventing a client hospitalized as an involuntary admission from leaving with the help of security is a valid intervention to ensure the safety of the client and others.
A man diagnosed with alcohol dependence experiences his first relapse. During his AA meeting, another group member states, I relapsed three times, but now have been sober for 15 years. Which of Yaloms curative group factors does this illustrate?
- A. Imparting of information
- B. Instillation of hope
- C. Catharsis
- D. Universality
Correct Answer: B
Rationale: The correct answer is B: Instillation of hope. This statement by the group member provides hope by showing that despite relapses, long-term sobriety is achievable. This aligns with Yalom's curative group factor of instillation of hope, where group members inspire and motivate each other through their own successes. The other choices are incorrect because:
A: Imparting of information focuses on sharing knowledge, not personal experiences.
C: Catharsis involves the release of emotions, not necessarily about hope for the future.
D: Universality is about realizing shared experiences, not specifically about hope for recovery.