Nokea
If this client is typical of others with phobias, which coping mechanism has the client most likely been using to deal with the fear of flying?
- A. Suppression
- B. Compensation
- C. Avoidance
- D. Undoing
Correct Answer: C
Rationale: Avoidance is the primary coping mechanism in phobias, as clients steer clear of the feared stimulus, such as refusing to fly.
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The nurse is planning care for the client who has a cognitive deficit and a history of violence following head trauma. What is the primary effect of a cognitive deficit that can contribute to the client having a catastrophically violent reaction?
- A. The client’s ability to process information including instructions is limited.
- B. The client has a decreased ability to interpret and tolerate sensory stimuli.
- C. The staff has a more difficult time providing appropriate milieu boundaries.
- D. The staff’s attention is oftentimes diverted to other more manipulative clients.
Correct Answer: B
Rationale: Decreased ability to tolerate sensory stimuli (B) triggers catastrophic reactions. Processing (A) boundaries (C) and staff attention (D) are not primary contributors.
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.
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.
The experienced nurse determines that the new nurse’s actions are therapeutic when managing the cognitively impaired client whose agitated behavior is escalating. Which nursing actions should have occurred? Select all that apply.
- A. Saying “Mr. Smith will you look at me please?”
- B. Saying “You seem upset. How can I help you?”
- C. Presenting the client with detailed expectations.
- D. Turning off the television in the room to decrease noise.
- E. Saying “Getting so angry will not help you get what you want.”
- F. Saying “Speaking as loud as the client to ensure that the client hears what is being said.”
Correct Answer: A ,B, D
Rationale: Using the client’s name (A) acknowledging upset (B) and reducing stimuli (D) calm agitation. Detailed expectations (C) challenging anger (E) or loud speech (F) may escalate.
Which question best assesses the client's long-term memory?
- A. What is your current age?
- B. What is today's date?
- C. What is your date of birth?
- D. What occurred last January?
Correct Answer: C
Rationale: Recalling date of birth tests long-term memory, as it requires retrieving well-established, distant personal information.