Nokea
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.
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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.
The nurse is aware that such attitudes and statements can have damaging consequences for a mentally ill client. What is the most significant consequence of the remark in this situation?
- A. It violates the client's right to treatment.
- B. It disregards the client's individuality.
- C. It interferes with continuity of client care.
- D. It disrupts good staff relationships.
Correct Answer: B
Rationale: Labeling the client as a hypochondriac dismisses their unique experiences, undermining person-centered care and trust.
When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?
- A. Do not bathe or shower.
- B. Make a sketch of the rapist.
- C. Write down what happened.
- D. Call a 911 operator.
Correct Answer: A
Rationale: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.
The older disheveled client is admitted to the ED with hypertension severe dehydration and malnourishment. During the admission interview the daughter notes that she and her husband who is temporarily out of work have been living with the client. Which nursing action is most important?
- A. Report the suspected elder abuse to Adult Health Protective Services.
- B. Ask additional questions of the client in private without the family present.
- C. Ask the daughter whether her father has been eating and taking his medication.
- D. Call the resource hotline to ask whether abuse and neglect should be considered.
Correct Answer: B
Rationale: Private questioning (B) elicits abuse/neglect details. Reporting (A) needs more evidence asking the daughter (C) is less direct and calling a hotline (D) is secondary.
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.