Nokea
When a client with dementia says, 'I want to go home,' which response by the nurse is most appropriate?
- A. You are at home.
- B. You are staying here.
- C. You must be homesick.
- D. You need to call your family.
Correct Answer: C
Rationale: Acknowledging homesickness validates the client's feelings, redirecting the conversation therapeutically without causing distress.
You may also like to solve these questions
When the depressed client is scheduled for a series of electroconvulsive therapy (ECT) treatments, which reaction is most likely to be manifested in the immediate recovery period?
- A. A brief period of absence seizures
- B. Sensitivity to light and double vision
- C. Short-term memory loss and headaches
- D. Periods of unexplained fear and anxiety
Correct Answer: C
Rationale: Short-term memory loss and headaches are common post-ECT effects due to temporary brain disruption.
The nurse is teaching the client with a substance abuse disorder about 12-step self-help programs such as AA. The nurse informs the client that the major principle associated with this 12-step program is what principle?
- A. Substance abuse disorders can be cured with total abstinence.
- B. Normal substance use can resume with the guidance and support of others.
- C. Acceptance of powerlessness over a substance is the first step in recovery.
- D. Substance abuse is a weakness that can be overcome through a belief in God.
Correct Answer: C
Rationale: AA’s first step is admitting powerlessness (C). Addiction is a disease not curable (A) or resumable (B) and not a weakness; higher power is personal (D).
When one older adult at reminiscence therapy says, 'If I had it to do all over again, I wouldn't change a thing,' the nurse is most accurate in interpreting this to mean that the client has acquired which developmental characteristic?
- A. Trust
- B. Integrity
- C. Intimacy
- D. Autonomy
Correct Answer: B
Rationale: Accepting one's life without regret reflects integrity, per Erikson's stage of integrity vs. despair in late adulthood.
The mother of the 14-year-old tells the clinic nurse that she is concerned that her child may be “doing some sort of drugs.” The adolescent is confused and has difficulty answering questions clearly but admits to sniffing solvents in the family’s garage. Which statement by the nurse is correct?
- A. “Most inhalants can cause serious nervous system and respiratory system damage.”
- B. “There is little risk for physical harm; the effects will wear off within a few hours.”
- C. “Your seeking help early can discourage your child from future drug experimentation.”
- D. “Due to hyperactivity now you will sleep for long periods after the drug effects are gone.”
Correct Answer: A
Rationale: Inhalants cause neurotoxicity and respiratory damage (A). They pose harm (B) early help (C) lacks context and insomnia follows (D).
If the rape victim shares all of the following information during a group session, which findings are most indicative of a severe adjustment reaction? Select all that apply.
- A. The victim reports feeling somewhat anxious.
- B. The victim describes having sporadic nightmares.
- C. The victim has lost weight and eats out of habit.
- D. The victim has occasional doubts about self-worth.
- E. The victim refuses to have sexual relations.
- F. The victim has started to drink wine before bedtime.
Correct Answer: B,C,E,F
Rationale: Nightmares, weight loss, sexual avoidance, and new alcohol use indicate significant distress and maladaptive coping, suggestive of a severe adjustment reaction.