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If a client is typical of other victims who remain in abusive relationships, what is the client most likely to believe?
- A. The client is not in any serious danger.
- B. The client can turn to the family for protection.
- C. The client can prevent the battering behavior.
- D. The client is free to leave the home at any time.
Correct Answer: C
Rationale: Victims often believe they can control or prevent the abuse, reflecting denial or rationalization that keeps them in the abusive situation.
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When debriefing the unit’s staff after the client’s catastrophic reaction the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse’s comment?
- A. The client’s safety is at jeopardy if the staff is feeling threatened.
- B. An agitated staff will not be able to manage the situation as effectively.
- C. The client will sense the staff’s agitation and aggressive behavior will escalate.
- D. An agitated staff response is indicative of a need for additional crisis-control training.
Correct Answer: C
Rationale: Staff agitation escalates client aggression (C). Safety (A) management (B) and training (D) are secondary concerns.
The nurse performs a physical assessment and collects the client's health history. Which assessment findings would the nurse expect to note as the client discusses the phobia related to flying? Select all that apply.
- A. Hypotension
- B. Tachycardia
- C. Tremors
- D. Shortness of breath
- E. Uncontrollable crying
- F. Facial tics
Correct Answer: B,C,D
Rationale: Discussing the phobia triggers anxiety, leading to tachycardia, tremors, and shortness of breath due to sympathetic activation.
Which nursing intervention is most beneficial for the client's spouse at this time?
- A. Suggesting that the spouse make an appointment for a physical examination
- B. Discussing modifying the amount of time the spouse devotes to care-giving
- C. Reminding the spouse of the scheduled times for visiting clients on the unit
- D. Explaining that many staff are available to care for the client
Correct Answer: B
Rationale: Modifying caregiving time reduces exhaustion, supporting the spouse's well-being while maintaining care responsibilities.
The client often avoids talking about cocaine use by refocusing on other problems such as losing a job and family discord. Which is the most helpful response by the nurse when the client avoids discussing using cocaine?
- A. “Has your cocaine use helped you to cope with these problems in the past?”
- B. “You need to consider that all these problems are related to your cocaine use.”
- C. “How do you think these problems will change once you no longer use cocaine?”
- D. “You can’t do anything about these while here. Just focus on getting off of cocaine.”
Correct Answer: C
Rationale: Linking drug use to problems (C) builds insight. Coping (A) is inaccurate opinions (B) cause defensiveness and avoiding issues (D) is unhelpful.
The nurse is caring for the client who is 2 days postadmission to a medical unit and has a long history of heavy alcohol abuse. The nurse should monitor for which acute complications related to alcohol abuse? Select all that apply.
- A. Seizures
- B. Pancreatitis
- C. GI bleeding
- D. Exophthalmos
- E. Delirium tremens
Correct Answer: A ,B ,C, E
Rationale: Seizures (A) pancreatitis (B) GI bleeding (C) and delirium tremens (E) are acute risks. Exophthalmos (D) is unrelated.