Nokea
What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship?
- A. Acknowledge the clients actions and generate alternative behaviors.
- B. Establish rapport and develop treatment goals.
- C. Attempt to find alternative placement.
- D. Explore how thoughts and feelings about this client may adversely impact care.
Correct Answer: B
Rationale: The correct answer is B: Establish rapport and develop treatment goals. During the introductory phase of the nurse-client relationship, establishing rapport is essential to build trust and a therapeutic alliance. Developing treatment goals collaboratively with the client sets the foundation for the care plan. This action promotes client engagement and empowerment. Acknowledging client actions and generating alternative behaviors (A) is more suited for later phases. Attempting to find alternative placement (C) is not appropriate in the introductory phase. Exploring how thoughts and feelings impact care (D) is important but not the priority during the orientation phase.
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During a therapeutic group, two clients engage in an angry verbal exchange. The nurse leader interrupts the exchange and excuses both of the clients from the group. The nurse has demonstrated which leadership style?
- A. Autocratic
- B. Democratic
- C. Laissez-faire
- D. Bureaucratic
Correct Answer: A
Rationale: The correct answer is A: Autocratic. This leadership style is characterized by making decisions independently and enforcing them without input from the group. In this scenario, the nurse leader interrupted the exchange and made the decision to excuse both clients without consulting the group. This approach is necessary in situations requiring immediate intervention to maintain order and ensure the safety of all group members.
Summary of other choices:
B: Democratic - In a democratic leadership style, decisions are made through group discussion and input from all members. This was not demonstrated in the scenario.
C: Laissez-faire - In a laissez-faire leadership style, the leader takes a hands-off approach and allows group members to make decisions. This was not demonstrated as the nurse leader took immediate action.
D: Bureaucratic - Bureaucratic leadership involves following strict rules and procedures. The scenario did not involve following predetermined rules but rather a quick decision made by the nurse leader.
A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?
- A. The client is placed in seclusion.
- B. The client is placed in a geriatric chair with tray.
- C. The client is placed in soft Posey restraints.
- D. The client is monitored by an ankle bracelet.
Correct Answer: D
Rationale: The correct answer is D - The client is monitored by an ankle bracelet. This option allows for monitoring and tracking the client's movements without physical restraint, promoting autonomy and freedom of movement. Seclusion (A) is restrictive and isolating. Placing the client in a geriatric chair with tray (B) limits mobility and can be degrading. Soft Posey restraints (C) restrict movement and can lead to physical and psychological harm. An ankle bracelet (D) is the least restrictive option as it allows for monitoring while still allowing the client some independence and mobility.
A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: Perhaps this was the best thing to happen. Maybe Ill look into pursuing an art degree. How should the nurse characterize the clients appraisal of the job loss stressor?
- A. Irrelevant
- B. Harm/loss
- C. Threatening
- D. Challenging
Correct Answer: D
Rationale: The correct answer is D: Challenging. The client's statement indicates a positive reframing of the job loss as an opportunity for personal growth. This suggests that the client views the situation as a challenge to adapt and pursue a new path. This perspective aligns with the concept of stress as a potential source of growth and development, known as the challenge appraisal.
Summary:
A: Irrelevant - The client's statement demonstrates relevance to his future plans, making this choice incorrect.
B: Harm/loss - The client's positive outlook does not reflect a perception of harm or loss, making this choice incorrect.
C: Threatening - The client's statement does not convey a perception of threat, making this choice incorrect.
Which should the nurse recognize as an example of the defense mechanism of repression?
- A. A woman whose son was killed in Iraq does not believe the military report.
- B. A man who is unhappily married goes to school to become a marriage counselor.
- C. A woman was raped when she was 12 and no longer remembers the incident.
Correct Answer: C
Rationale: The correct answer is C because repression is a defense mechanism in which traumatic memories are unconsciously blocked from awareness. In this scenario, the woman's inability to remember the rape incident at age 12 is a classic example of repression. She has pushed the memory out of consciousness to avoid the emotional distress associated with it.
Choice A is incorrect as it describes denial, where the woman refuses to accept the truth. Choice B is incorrect as it reflects sublimation, where the man channels his unhappiness into a positive pursuit. Choice D is incomplete, making it impossible to evaluate.
At what point should the nurse determine that a client is at risk for developing a mental disorder?
- A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
- B. When maladaptive responses to stress are coupled with interference in daily functioning
- C. When the client communicates significant distress
- D. When the client uses defense mechanisms as ego protection
Correct Answer: B
Rationale: The correct answer is B. When maladaptive responses to stress are coupled with interference in daily functioning, the nurse should determine that a client is at risk for developing a mental disorder. This is because maladaptive responses to stress, such as excessive worry or avoidance behaviors, can be early signs of mental health issues. When these responses start impacting daily functioning, such as affecting work or relationships, it indicates a higher level of risk for a mental disorder. Choices A, C, and D are incorrect because they do not specifically address the combination of maladaptive responses to stress and interference in daily functioning, which are key indicators of potential mental health issues.