Nokea
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.
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While sitting in the day-room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrates the client's behaviors. Which is the main goal of this therapeutic technique?
- A. Initiate a non-threatening conversation with the client
- B. Allow the client to identify the way he interacts
- C. Dialog about the ineffectiveness of his interactions
- D. Discuss the client's feelings when he responds
Correct Answer: B
Rationale: The technique aims to allow the client to observe his own behaviors, fostering self-awareness. Initiating conversation, dialoguing about ineffectiveness, or discussing feelings are secondary to promoting insight through self-observation.
The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?
- A. Alcohol
- B. Benzodiazepine
- C. Methamphetamine
- D. Marijuana
Correct Answer: C
Rationale: Methamphetamine use is known to cause significant cardiovascular effects, including increased heart rate, blood pressure, and vasoconstriction, which can lead to myocardial infarction. Excessive alcohol consumption can contribute to cardiovascular issues but is less potent than methamphetamine. Benzodiazepines primarily affect the central nervous system, not the cardiovascular system. Marijuana has cardiovascular effects but is generally less risky than methamphetamine.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A middle-aged man who is complaining of shortness of breath and is diaphoretic
- B. A young woman who suddenly goes blind with no indication of organic pathology
- C. An older adult who continuously complains of a headache and back pain
- D. An adolescent who becomes extremely anxious about going outside
Correct Answer: B
Rationale: Sudden blindness with no organic pathology suggests a functional neurological symptom disorder, which falls under conversion disorder. Shortness of breath and diaphoresis may indicate a medical condition or panic attack. Headaches and back pain could have various causes. Anxiety about going outside suggests agoraphobia or another anxiety disorder.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy
- B. Demonstrates effective ways to cope with anxiety
- C. Learns methods of relaxation to reduce anxiety
- D. Takes all antianxiety medications as prescribed
Correct Answer: B
Rationale: This outcome directly addresses the client's maladaptive coping mechanism (scratching wrists) by aiming to replace it with healthier strategies. Therapy participation and relaxation methods are important but secondary to effective coping. Medication adherence does not teach alternative coping strategies.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation
- C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed
- D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm
Correct Answer: A
Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.