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The nurse admits a client diagnosed with Alzheimer disease. The client is mildly anxious and very confused. Which action does the nurse take?
- A. Remain with the client and begin explaining the environment.
- B. Give the client a copy of the unit rules and procedures.
- C. Ask the client to sign a consent form for medications.
- D. Orient the client to self, day, time, place, and situation.
Correct Answer: D
Rationale: Orienting the client to self, day, time, place, and situation addresses confusion and anxiety, providing a calming and grounding effect. Explaining the environment is helpful but less structured, and rules or consent forms are inappropriate given the client’s confusion.
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Which dysfunction of the reproductive system is associated with anorexia nervosa in females?
- A. Galactorrhea
- B. Gynecomastia
- C. Amenorrhea
- D. Premenstrual dysphoric disorder
Correct Answer: C
Rationale: Amenorrhea (cessation of menses) is associated with anorexia nervosa in females due to endocrine imbalances resulting from depleted fat stores. Galactorrhea is a milky discharge from the nipples unrelated to normal breast milk production. Gynecomastia is swelling of breast tissue in males. Premenstrual dysphoric disorder occurs about 1 week before menses and includes mood swings, depression, fatigue, bloating, overeating, and difficulty focusing, resolving when menstruation starts. In the context of anorexia nervosa, the primary concern is the disruption of the menstrual cycle due to low body weight, leading to amenorrhea.
Which parental statement would the nurse recognize as the appropriate application of time-out when disciplining a 4-year-old?
- A. I send my child to their bedroom for misbehaving.
- B. We limit time-out to 4 minutes per incident.
- C. Putting my child in a dark closet for time-out is very effective.
- D. I explain the reason for the time-out before and after disciplining my child.
Correct Answer: D
Rationale: The correct answer is to explain the reason for the time-out before and after disciplining the child. This approach reinforces the child's association of the time-out with the undesirable behavior, helping the child learn to control those behaviors. Sending a child to their bedroom may lead to negative associations with bedtime or be ineffective if the child enjoys spending time in their bedroom. Time-out should ideally be limited to 1 minute per year of age, so a time-out for a 4-year-old should be limited to 4 minutes. Placing a child in a dark closet can create fear and damage the child's trust in their parents as a source of safety, making it an inappropriate and harmful approach. Even if this method seems effective in the short term, the potential long-term consequences outweigh any immediate benefits.
What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?
- A. Scheduling pain medication at regular intervals
- B. Administering the medication only when the pain is severe
- C. Avoiding the administration of medication unless it is requested
- D. Recognizing that less pain medication will be needed by this client compared with other women in labor
Correct Answer: A
Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.
The nurse leads group therapy for clients diagnosed with substance abuse. A client diagnosed with alcoholism, and who occasionally uses marijuana and cocaine, attends the meeting. During the meeting the client states, 'I am having trouble sitting still. Am I bothering anybody? Maybe I should not come to these meetings.' Which action by the nurse is most appropriate?
- A. Encourage the client to share problems with the group.
- B. Remove the client from the group and further assess needs.
- C. Recognize this as manipulative behavior and encourage the client to remain in the group.
- D. Tell the other group members to ignore the client and continue with the group meeting.
Correct Answer: A
Rationale: Encouraging the client to share promotes engagement and allows the group to support them, addressing their restlessness therapeutically. Removing them isolates, labeling as manipulative is judgmental, and ignoring dismisses their needs.
What feeling is likely to result from withdrawn behavior?
- A. Anger
- B. Paranoia
- C. Loneliness
- D. Boredom
Correct Answer: C
Rationale: Withdrawn behavior involves avoiding social interactions and isolating oneself. This isolation can lead to feelings of loneliness as the individual lacks connection and companionship. While anger or paranoia may contribute to withdrawal, loneliness is a common emotional consequence of prolonged social isolation. Boredom may also arise from withdrawal if meaningful activities and social engagements are reduced.