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If the client is typical of others of similar age, the nurse can anticipate the client as having which age-related problems? Select all that apply.
- A. Becoming cynical
- B. Losing patience
- C. Developing hostility
- D. Having periods of regret
- E. Experiencing episodes of depression
Correct Answer: D,E
Rationale: Regret and depression are common in late adulthood as individuals reflect on life, per Erikson's integrity vs. despair stage.
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When asked to identify the characteristics of post-traumatic stress disorder (PTSD), the nurse correctly responds that most people with this disorder report which findings? Select all that apply.
- A. Recurring nightmares
- B. Auditory hallucinations
- C. Rapidly changing emotions
- D. Flashbacks
- E. Ease in being startled
- F. Trouble concentrating
Correct Answer: A,D,E,F
Rationale: PTSD symptoms include nightmares, flashbacks, hyperarousal (easily startled), and concentration difficulties, reflecting trauma-related distress.
When the rape victim arrives at the emergency department, which nursing action is best for relieving the client's anxiety?
- A. Determine the victim's last date of menstruation.
- B. Collect evidence for criminal prosecution.
- C. Assess the extent of the client's injuries.
- D. Stay with the client at all times.
Correct Answer: D
Rationale: Remaining with the victim provides emotional support and a sense of safety, directly addressing anxiety during a traumatic experience.
When discussing obesity, which comment best indicates that the client is using the coping mechanism of rationalization to deal with being overweight?
- A. I have many health risks from being obese.
- B. I eat because I am under stress.
- C. I know you don't like me because I'm fat.
- D. I can't help being overweight; it's in my genes.
Correct Answer: D
Rationale: Blaming genetics for obesity is rationalization, as it justifies the condition by attributing it to an uncontrollable factor.
The nurse is preparing to administer thiamine (vitamin B1) to the client receiving treatment for alcohol dependence. Which statement best describes the rationale for the use of thiamine?
- A. Thiamine improves the absorption of other essential vitamins and folic acid.
- B. Thiamine helps to reverse the malnutrition often associated with alcohol abuse.
- C. Thiamine reduces the risk of seizures occurring during withdrawal from alcohol.
- D. Thiamine prevents neuropathy and confusion associated with chronic alcohol use.
Correct Answer: D
Rationale: Thiamine prevents neuropathy and confusion from deficiency (D). It doesn’t aid absorption (A) malnutrition reversal (B) is secondary and seizures (C) need anticonvulsants.
Multiple clients are being cared for on the behavioral health unit. In which circumstances should the nurse plan the therapeutic use of seclusion and/or restraints? Select all that apply.
- A. The client asks to be placed in seclusion.
- B. The client expresses the likelihood of self-injury.
- C. The staff feels the client is likely to harm others.
- D. A legally detained client is threatening to “escape.”
- E. The staff identifies seclusion as a consequence of the client’s behavior.
- F. The client’s threatening behavior is negatively affecting the therapeutic milieu.
Correct Answer: A, B ,C, D
Rationale: Seclusion/restraints are therapeutic for client request (A) self-injury risk (B) harm to others (C) or escape threats (D). Punishment (E) or milieu disruption (F) alone are not indications.