Nokea
The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?
- A. I noticed you were looking out the window when discussing your feelings.
- B. I think you're lying and it bothers you that your children aren't coming.
- C. I think you should discuss your children not coming in the group meeting.
- D. Why do you think your children didn't want to come visit you this weekend?
Correct Answer: A
Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.
You may also like to solve these questions
The LPN/LVN is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?
- A. Acute psychiatric illnesses impair intelligence.
- B. Intelligence is influenced by social and cultural factors.
- C. Poor concentration skills suggest limited intelligence.
- D. The inability to think abstractly indicates limited intelligence.
Correct Answer: B
Rationale: The correct answer is B because intelligence is influenced by social and cultural factors. Social and cultural beliefs can impact how intelligence is perceived and expressed. Choice A is incorrect because acute psychiatric illnesses can affect cognitive functioning but not necessarily intelligence. Choice C is incorrect because poor concentration skills do not always correlate with limited intelligence. Choice D is incorrect because the inability to think abstractly is just one aspect of intelligence and does not solely indicate limited intelligence.
A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:
- A. Engaging in immoral acts
- B. Always reinforcing self-approval
- C. Observing rigid rules and regulations
- D. Having the need always to make the right decision
Correct Answer: C
Rationale: Clients with anorexia nervosa often manage anxiety by adhering strictly to rules and regulations as a way to maintain control. Choice A is incorrect because engaging in immoral acts is not a common coping mechanism for clients with anorexia nervosa. Choice B is incorrect as self-approval is not typically the primary way clients with anorexia nervosa manage anxiety. Choice D is incorrect because while clients with anorexia nervosa may have a need to make the right decision, it is not the primary way they manage their anxiety.
A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Encourage the client to perform facial exercises.
- C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
- D. Document the findings and continue to monitor the client.
Correct Answer: C
Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.
The nurse is leading a 'current events group' with chronic psychiatric clients. One group member states, 'Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me.' Which response would be best for the nurse to make?
- A. 'Clara Barton was not your nurse.'
- B. 'What did she do to you that was so mean?'
- C. 'I didn't know that Clara Barton was a nurse.'
- D. 'Clara Barton started the American Red Cross.'
Correct Answer: D
Rationale: (D) presents the reality of the situation in relation to American culture. The fact that Clara Barton was a nurse during the Civil War should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Therefore, the most appropriate response is (D) as it provides factual information that can redirect the conversation in a constructive manner.
Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate?
- A. I need to inform the healthcare provider about your child's tendency to be accident-prone.
- B. Tell me more specifically about your child's accidents.
- C. I must report these injuries to the authorities because they do not seem accidental.
- D. Boys this age always seem to require more supervision and can be quite accident-prone.
Correct Answer: B
Rationale: (B) seeks more information in a non-threatening manner to gather additional details about the child's accidents. This response allows the nurse to explore the situation further without making assumptions. (A) fails to address the concerning findings and instead focuses on informing the healthcare provider. (C) jumps to conclusions without gathering more information, potentially causing unnecessary distress to the family. (D) dismisses the seriousness of the situation by attributing the injuries to common accidents for boys, missing the opportunity to delve deeper into the issue.