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If the client admits that incidences of domestic abuse are occurring, which nursing intervention is most beneficial?
- A. Offering the victim money to leave home
- B. Identifying resources for shelter and safety
- C. Recommending termination of the abusive relationship
- D. Suggesting joint counseling with a therapist or clergyman
Correct Answer: B
Rationale: Providing resources for shelter and safety ensures the victim's immediate protection and access to support, addressing the urgent need for security.
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Which nursing action is most appropriate at this time?
- A. Criticize the nature of the client's rude behavior.
- B. Support the emaciated client who was targeted by the remark.
- C. Invite others in the group to respond to the situation.
- D. Embarrass the bulimic client with a similar comment.
Correct Answer: B
Rationale: Supporting the targeted client validates their feelings and maintains a safe group environment, addressing the immediate emotional impact.
The best rationale for having the client reflect on the statements is that during the middle years of life, adults tend to do what?
- A. Assess their accomplishments
- B. Set unreasonable goals
- C. Envy others' achievements
- D. Doubt their judgment
Correct Answer: A
Rationale: Middle adulthood involves evaluating life achievements, per Erikson's generativity vs. stagnation stage, often prompting reflection on regrets.
The nurse is unavoidably late in changing the dressing on the client’s leg. The client reacts by becoming verbally aggressive and telling the nurse “None of you can be trusted. You all just make promises you never intend to keep.” Which should be the nurse’s initial action?
- A. Alert other staff to the client’s apparent escalation.
- B. Ask why the client is overreacting to the situation.
- C. Leave the room until the client has regained control.
- D. Apologize to the client for being late with the treatment.
Correct Answer: D
Rationale: Apologizing (D) validates the client’s distress and acknowledges the nurse’s role de-escalating the situation. Alerting staff (A) is secondary asking why (B) may escalate defensiveness and leaving (C) avoids communication.
The mother of the 14-year-old tells the clinic nurse that she is concerned that her child may be “doing some sort of drugs.” The adolescent is confused and has difficulty answering questions clearly but admits to sniffing solvents in the family’s garage. Which statement by the nurse is correct?
- A. “Most inhalants can cause serious nervous system and respiratory system damage.”
- B. “There is little risk for physical harm; the effects will wear off within a few hours.”
- C. “Your seeking help early can discourage your child from future drug experimentation.”
- D. “Due to hyperactivity now you will sleep for long periods after the drug effects are gone.”
Correct Answer: A
Rationale: Inhalants cause neurotoxicity and respiratory damage (A). They pose harm (B) early help (C) lacks context and insomnia follows (D).
Which clients are most likely to be members of an obsessive-compulsive disorder (OCD) support group? Select all that apply.
- A. A 30-year-old who performs handwashing five times per hour
- B. A 35-year-old who wears gloves when touching a public faucet
- C. A 40-year-old who is sexually promiscuous
- D. A 45-year-old who drinks a fifth of whiskey daily
- E. A 50-year-old who cannot throw anything away
- F. A 60-year-old who repeatedly checks the locks on locked doors
Correct Answer: A,B,E,F
Rationale: Compulsive handwashing, glove-wearing, hoarding, and lock-checking are characteristic OCD behaviors involving repetitive actions to reduce anxiety.