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The client's family asks the nurse for a list of organizations where they can go for support during this difficult time. Which resource is most appropriate in this situation?
- A. Alcoholics Anonymous
- B. Recovery Anonymous
- C. Al-Anon
- D. Synanon
Correct Answer: C
Rationale: Al-Anon is specifically designed to support family members of individuals with alcoholism, providing them with coping strategies and emotional support.
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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 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.
The nurse is unavoidably late in changing the dressing on the client’s leg. The client reacts by becoming verbally aggressive and telling the nurse “None of you can be trusted. You all just make promises you never intend to keep.” Which should be the nurse’s initial action?
- A. Alert other staff to the client’s apparent escalation.
- B. Ask why the client is overreacting to the situation.
- C. Leave the room until the client has regained control.
- D. Apologize to the client for being late with the treatment.
Correct Answer: D
Rationale: Apologizing (D) validates the client’s distress and acknowledges the nurse’s role de-escalating the situation. Alerting staff (A) is secondary asking why (B) may escalate defensiveness and leaving (C) avoids communication.
Which nursing action is most appropriate at this time?
- A. Criticize the nature of the client's rude behavior.
- B. Support the emaciated client who was targeted by the remark.
- C. Invite others in the group to respond to the situation.
- D. Embarrass the bulimic client with a similar comment.
Correct Answer: B
Rationale: Supporting the targeted client validates their feelings and maintains a safe group environment, addressing the immediate emotional impact.
If the rape victim shares all of the following information during a group session, which findings are most indicative of a severe adjustment reaction? Select all that apply.
- A. The victim reports feeling somewhat anxious.
- B. The victim describes having sporadic nightmares.
- C. The victim has lost weight and eats out of habit.
- D. The victim has occasional doubts about self-worth.
- E. The victim refuses to have sexual relations.
- F. The victim has started to drink wine before bedtime.
Correct Answer: B,C,E,F
Rationale: Nightmares, weight loss, sexual avoidance, and new alcohol use indicate significant distress and maladaptive coping, suggestive of a severe adjustment reaction.