Nokea
One day the client's daughter states to the nurse, 'I'm not sure my mom recognizes me.' Which response by the nurse is most therapeutic?
- A. It may be probably the beginning of the end.
- B. You're distressed that there isn't an appropriate response to you.
- C. Don't worry. The standard of care is being delivered.
- D. There will be good days and bad days. Today is a bad day.
Correct Answer: B
Rationale: Acknowledging the daughter's distress validates her emotions, fostering therapeutic communication and support.
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When providing care for an Asian client diagnosed with mental illness, which barriers should be considered before the treatment? Select all that apply.
- A. Language
- B. Literacy
- C. Somatization of mental health symptoms
- D. Food preferences
- E. Client's tendency to give limited information
- F. Financial status
Correct Answer: A,C,E
Rationale: Language barriers, somatization, and limited disclosure are common cultural factors in Asian clients, impacting mental health treatment access.
If the home health nurse documented all of the following findings, which one is most suggestive that the client is depressed?
- A. The client is irritable after grandchildren visit.
- B. The client has multiple, unrelated physical complaints.
- C. The client takes lengthy naps in the late afternoon.
- D. The client cries when talking about a dead spouse.
Correct Answer: B
Rationale: Multiple somatic complaints are a hallmark of depression in older adults, often masking emotional symptoms.
The nurse observes that the client diagnosed with intermittent explosive disorder is becoming aggressive and that lorazepam was prescribed. The client is now exhibiting a tense posture a clenched fist and a defiant affect. Prioritize the nurse’s actions to de-escalate the client’s aggression.
- A. Call other staff for assistance.
- B. Attempt to talk the client down.
- C. Apply wrist restraints.
- D. Offer client choice of taking medication voluntarily.
- E. Provide alternate use of physical energy such as suggesting punching a pillow.
Correct Answer: B ,E ,D ,A, C
Rationale: Talk down (B) builds trust offering physical outlets (E) releases tension medication choice (D) calms staff assistance (A) ensures safety and restraints (C) are last resort for harm prevention.
Which assessment finding is most atypical of a 65-year-old client?
- A. Making errors in copying a line drawing
- B. Forgetting the names of longstanding neighbors
- C. Reading information slowly
- D. Naming only two of the last three presidents
Correct Answer: A
Rationale: Errors in copying a drawing suggest visuospatial deficits, less common in typical aging and more indicative of neurological issues.
The nurse counsels the team member privately about the inappropriate remark. What is the first step in understanding the behavior of clients?
- A. Understanding one's own behavior
- B. Analyzing what motivates clients' behavior
- C. Becoming more familiar with abnormal behavior
- D. Taking courses in counseling
Correct Answer: A
Rationale: Self-awareness of personal biases is the first step to understanding client behavior, ensuring objective and empathetic care.