Nokea
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.
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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.
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.
Which finding in the client's history strongly suggests lack of achieving the characteristic developmental level expected at this age in the life cycle?
- A. The client drifts in and out of relationships.
- B. The client worries about financial security.
- C. The client questions personal sexual identity.
- D. The client hesitates to be assertive.
Correct Answer: A
Rationale: Drifting in and out of relationships indicates difficulty achieving intimacy, a key developmental task of young adulthood per Erikson's stages.
The female client tells the nurse “I usually have a few drinks after work but I always limit it to three. I’m not risking becoming addicted am I?” What is the nurse’s best response?
- A. “There is no harm in social drinking as long as you know your limits and you are not driving while intoxicated.”
- B. “As long as you don’t have any social problems associated with your use of alcohol you do not need to be concerned.”
- C. “If you are concerned about the frequency and the number of drinks consumed then you might be developing a dependency.”
- D. “Three drinks a day or seven drinks in a week is high-risk drinking for women. You seem concerned that you might have an alcohol dependency.”
Correct Answer: D
Rationale: Three drinks daily or seven weekly is high-risk for women (D). Social drinking (A) or social problems (B) don’t address risk and concern alone (C) misses education.
The nurse is educating the client on the methadone prescribed for replacement therapy while in an outpatient treatment program for heroin addicts. The client asks how taking a pill is going to help the client stay substance-free. Which statement is the nurse’s best reply?
- A. “The methadone will give you the same high so you won’t want heroin anymore.”
- B. “The methadone will cause you to become very sick if you take heroin at the same time”
- C. “The methadone ‘replaces’ heroin in your body so you will have fewer cravings for heroin.”
- D. “The methadone causes sedation; you’ll sleep better so you can participate in your treatment.”
Correct Answer: C
Rationale: Methadone displaces heroin reducing cravings (C). It doesn’t produce a high (A) cause sickness (B) or sedate (D).