Nokea
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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When a client with dementia says, 'I want to go home,' which response by the nurse is most appropriate?
- A. You are at home.
- B. You are staying here.
- C. You must be homesick.
- D. You need to call your family.
Correct Answer: C
Rationale: Acknowledging homesickness validates the client's feelings, redirecting the conversation therapeutically without causing distress.
The nurse is discharging the client from an inpatient treatment program for cocaine abuse. Which statement by the client indicates an accurate understanding about the disease process of addiction?
- A. “I’m really going to try to stay off cocaine. I’m not worried about alcohol since I’ve never had any problem with a glass or two of wine with dinner.”
- B. “Once my cravings go away I won’t need to go to Narcotics Anonymous (NA) anymore. I’ll be recovered and will be able to stay away from using cocaine.”
- C. “I feel much better after talking to my therapist. I didn’t realize that I was hurting so much emotionally. I must have been using to deal with my emotional problems.”
- D. “I didn’t realize that staying off drugs meant changing my thoughts and emotions. I thought I could just learn to stop using cocaine. NA will help me make these changes.”
Correct Answer: D
Rationale: Lifestyle change via NA (D) is key to recovery. Other substances (A) risk dependency recovery is lifelong (B) and addiction is primary not emotional (C).
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.
When one older adult at reminiscence therapy says, 'If I had it to do all over again, I wouldn't change a thing,' the nurse is most accurate in interpreting this to mean that the client has acquired which developmental characteristic?
- A. Trust
- B. Integrity
- C. Intimacy
- D. Autonomy
Correct Answer: B
Rationale: Accepting one's life without regret reflects integrity, per Erikson's stage of integrity vs. despair in late adulthood.
On the basis of this change in the client's condition, which nursing action is most appropriate to perform next?
- A. Identifying the client's religious preference
- B. Calling the nursing supervisor
- C. Notifying the physician
- D. Documenting the assessed data in the client's chart
Correct Answer: C
Rationale: Notifying the physician promptly addresses the acute change (delirium tremens), ensuring rapid intervention for a potentially life-threatening condition.