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The nurse talks with a child who has been sexually abused by a family member. The child asks the nurse, 'If I tell you something, will you tell anyone my secret?' Which response by the nurse to the client is appropriate?
- A. I will not tell anyone your secret.
- B. I will not tell your mom and dad.
- C. I'll call the nursing supervisor as a witness.
- D. I cannot keep this information a secret.
Correct Answer: D
Rationale: Nurses are mandated reporters and cannot promise confidentiality in cases of abuse, as reporting to authorities is required to protect the child. This response is honest and maintains trust while adhering to legal and ethical obligations.
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The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands which to be correct regarding group therapy?
- A. The termination stage begins with the initial group meeting.
- B. Members' feelings about their accomplishments are explored in the working stage.
- C. During the working stage, members may be unclear about the purpose of the group.
- D. Group roles and responsibilities are established in the working stage of group therapy.
Correct Answer: D
Rationale: Group roles and responsibilities are established in the working stage, when members actively engage in therapeutic goals.
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
- A. The client's blood pressure is 180/96 mm Hg.
- B. The client has right-sided weakness.
- C. The client has tinnitus.
- D. The client invents elaborate, improbable events.
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.
The nurse evaluates the client response to a 2-week trial of electroconvulsive therapy (ECT). Which data indicates to the nurse that treatment is successful?
- A. The client no longer experiences phobias and anxiety.
- B. The client no longer counts objects out loud.
- C. The client is no longer mute and withdrawn.
- D. The client no longer displays overreaction to events.
Correct Answer: C
Rationale: ECT is primarily used for severe depression or catatonia. A client no longer being mute and withdrawn indicates improved engagement and mood, suggesting successful treatment. Other options are less directly associated with ECT outcomes.
A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which should the nurse plan to include as part of one of these discussions?
- A. Ongoing fluid restriction
- B. The need for genetic counseling
- C. The risk of hypotensive episodes
- D. Depression regarding massive edema
Correct Answer: B
Rationale: Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and the extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
The nurse is assessing a client who was just admitted to the psychiatric unit. The client says, 'You won't have to worry about me much longer.' Which meaning should the nurse interpret from this statement?
- A. An intention of suicide
- B. An expression of depression
- C. An intention of self-mutilation
- D. An expression of hopelessness
Correct Answer: A
Rationale: A client who is at risk for suicide who says, 'You won't have to worry about me much longer,' is making an expression of a suicidal intent. Although depression, self-mutilation, and hopelessness may relate to violence to oneself, the statement that he or she will not be around is a direct comment about the act of suicide.