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The nurse conducts a grief support group at the community mental health center. Which client will the nurse identify as needing additional assistance before participating in this group?
- A. Older adult male whose estranged spouse, living in another state, died from heart disease 3 months ago.
- B. Older adult female whose spouse died 3 years ago in a car accident.
- C. Middle-aged female who started drinking after the sudden death of the spouse 6 months ago.
- D. Young male with two children whose spouse died 1 year ago due to breast cancer.
Correct Answer: C
Rationale: The middle-aged female who began drinking after her spouse’s death indicates unhealthy coping and potential substance abuse, requiring individual intervention before group participation. Other clients show grief but no immediate maladaptive behaviors.
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The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
The parent of an infant client with tetralogy of Fallot (TOF) is pumping her breasts at the client's bedside. The unlicensed assistive personnel (UAP) says to the nurse, 'She should breast feed that baby instead of pumping all the time. What's wrong with her?' Which is the best response for the nurse to make?
- A. You sound upset about what you observed.
- B. Why don't you ask her why she is pumping?
- C. What do you understand about her baby's illness?
- D. It's not our business to judge the decisions of others.
Correct Answer: C
Rationale: Asking the UAP about their understanding of the baby’s condition encourages education and clarifies why pumping may be necessary (e.g., due to the infant’s cardiac condition). This promotes teamwork and understanding without judgment or confrontation.
A client diagnosed with acute kidney injury is having trouble remembering information and instructions as a result of altered laboratory values. Which actions should the nurse take when communicating with this client? Select all that apply.
- A. Give simple, clear directions.
- B. Include the family in discussions related to care.
- C. Explain treatments using understandable language.
- D. Explain the possibility of hemodialysis in simple terms.
- E. Give thorough and complete explanations of treatment options.
Correct Answer: A,B,C,D
Rationale: The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and altered laboratory values. Communications should be clear, simple, and understandable. The family is included whenever possible. Information about treatment should be explained using understandable language. Thorough and complete explanations may be confusing and will not be understandable for the client.
A client diagnosed with an obsessive-compulsive disorder spends many hours during the day and night washing hands. The nurse should initially allow the client to continue this behavior because it has what therapeutic effect for the client?
- A. Relieves the client's anxiety
- B. Decreases the chance of infection
- C. Gives the client a feeling of self-control
- D. Increases the client's sense of self-esteem
Correct Answer: A
Rationale: The compulsive act provides immediate relief from anxiety and is used to cope with stress, conflict, or pain. Options 2 and 3 are also incorrect interpretations of the client's need to perform this behavior. Although the client may feel the need to increase self-esteem, that is not the primary goal of this behavior.
The nurse is assessing a client to determine the client's adjustment to presbycusis. Which indicates successful adaptation by the client to this problem?
- A. Proper use of a hearing aid
- B. Denial of a hearing impairment
- C. Withdrawal from social activities
- D. Reluctance to answer the telephone
Correct Answer: A
Rationale: Presbycusis occurs as part of the aging process; it is a progressive sensorineural hearing loss. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Some clients may not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid.